Crestmoor Care Center
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Actual harm Residents Affected - Few
elsewhere. He said he usually came back to the facility drunk. He said that the facility discouraged him from drinking, but there were no real consequences. He said that he often felt like the other residents and staff were talking poorly of him, so he felt like he had to talk (expletive) to them.
Resident #4 said that many people in the facility had bad attitudes and he often wanted to beat them up if
they said disrespectful things to him. He said that his fights with residents were usually because other residents made false claims about his ethnic heritage. He said that made him very angry and that was why
he would beat others up.
Resident #4 said staff tried to keep residents apart from one another when they got into fights, but did not do anything to intervene when one resident was being disrespectful or threatening another resident. He said most of the time, the staff did not notice or ignored that behavior.
- 3. Record review
- 1. Resident status
- 15. The resident was not aggressive towards others. The assessment revealed Resident #9 needed
The behavioral care plan, initiated on [DATE REDACTED], documented Resident #4 occasionally returned to the facility from the community intoxicated. The care plan documented when the resident was intoxicated, he could become verbally and physically aggressive towards staff and residents. Pertinent interventions included while the resident appeared intoxicated, the staff were to provide the resident one-to-one observation. -However, the facility was unable to provide documentation that one-to-one observations were completed when Resident #4 was intoxicated on [DATE REDACTED], [DATE REDACTED] and [DATE REDACTED].
A review of the resident's behavioral tracking sheets, from [DATE REDACTED] through [DATE REDACTED], revealed that staff did not document any of the incidents of aggressive behavior towards others, as documented in the resident's
record and in the incident investigation.
C. Resident #5 (victim)
Resident #5, age less than 65, was admitted to the facility on [DATE REDACTED] and was discharged in [DATE REDACTED].
According to the [DATE REDACTED] CPO, diagnoses included heart failure, diabetes and anemia.
The [DATE REDACTED] MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of
substantial/ maximum assistance with ADLs involving mobility of his lower body (legs, hips and feet) and was independent with ADLs involving the uses of his upper body (hands, shoulders and arms). The resident used a manual wheelchair to get around independently.
VI. Incident of verbal abuse by Resident #4 and Resident #11 towards Resident #9 on [DATE REDACTED] A. Facility investigation
The facility investigation, dated [DATE REDACTED], documented
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
CRESTMOOR CARE CENTER in DENVER, CO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DENVER, CO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CRESTMOOR CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.