Crestwood Health Care Center, Llc

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

support) for 12 minutes with ROSC (return of spontaneous circulation) achieved, intubated (a procedure that's used when you can't breathe on your own. A tube is placed down the throat into the windpipe to make

it easier to get air into and out of your lungs.) and brought to ED;-Drugs of Abuse Screen: Positive for: Oxycodone (would be expected due to physician's order), cannabinoids, cocaine and fentanyl; -Assessment and Plan: Functional Status: Poor; Decisional Capacity: Unreliable; Disease Extent: Serious and reversibility: Poor;-Disease-directed treatment options: Palliative (a specialized form of care for people living with serious illness. It helps relieve symptoms and stress, physical, emotional, spiritual, and practical, while improving quality of life.);-Hospice (end of life care) Eligibility: Based on current function, current medical issues, and prognosis models, the resident is eligible for Hospice;-discharged on [DATE REDACTED].Review of the resident's Hospice admission record from the hospital, showed:-Date of admission: [DATE REDACTED];-Inpatient Hospice History and Physical: High risk for complications and death due to advanced disease with limited life expectancy of days to a week. Symptoms requiring GIP Care (general inpatient care)/Chief Complaint: Uncontrolled pain, uncontrolled anxiety/psychosocial distress, uncontrolled restlessness/agitation, uncontrolled dyspnea (difficult breathing) and uncontrolled secretions;-Review of Systems: Unable to review due to mental status changes from terminal illness;-Physical Exam, General: Critically ill appearing, lying in bed. Pulmonary: Mechanically ventilated, no accessory muscle (the use of muscles other than the primary respiratory muscles to assist in breathing) use. Neurological: Nonfocal (not localized or concentrated in one specific area), generally weak; -Assessment/Plan: Hospice, diagnosis: anoxic encephalopathy. Progressive disease. No longer seeking treatment. Transitioned to Hospice. Focus of care is comfort and symptom management. Support patient and family with IDG (interdisciplinary group) during transition to end of life;-Plan: Continue comfort medications. Hospice following.5. Review of Resident #1's quarterly MDS dated [DATE REDACTED], and located in the EMR, showed: -Makes Self Understood: Understood;-Ability To Understand Others: Understands;-Cognitively intact;-Inattention, Disorganized Thinking, Altered Level of Consciousness: Behavior not exhibited;-Potential Indicators of Psychosis: Delusions;-Physical, Verbal, or Other Behavioral Symptoms: Behaviors not exhibited;-Rejection of Care: Behavior not exhibited;-Diagnoses of anxiety, depression, psychotic disorder and schizophrenia;-High-Risk Drug Classes: Antipsychotics and antianxiety.Review of the resident's care plan, located in the EMR, showed:-[DATE REDACTED], Problem: Independent with ADLs. Goal: Will have no decline in ADL performance. Interventions: Provide protective oversight

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crestwood Health Care Center, LLC

11400 Mehl Avenue Florissant, MO 63033

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

120 (systolic)/80 (diastolic)) and entered a 5/hold/see progress notes.Review of the resident's weights/vitals tab, located in the EMR, showed the CMT documented: [DATE REDACTED] at 10:56 A.M., BP 78/67.Review of the resident's progress notes, located in the EMR, showed:-No documentation regarding the resident's BP of 78/67;-[DATE REDACTED] at 3:49 P.M. and documented by Registered Nurse (RN) F: 11:00 A.M., resident observed lying in bed talking to this writer and treatment nurse while taking medication and supplement. Resident verbally denied pain when asked. 11:48 A.M., code blue (a medical emergency), coffee ground emesis (vomit that resemble coffee grounds due to the presence of old, coagulated blood, indicating bleeding in the upper gastrointestinal tract that requires immediate medical attention). No pulse, no respiration, CPR initiated, 911 called. 12:24 P.M., resident pronounced dead.During an interview on [DATE REDACTED] at 6:58 A.M., Licensed Practical Nurse (LPN) R said if a resident had a BP of 78/67, he/she would hold any BP medications and call the physician. He/She would document the BP and any new physician orders in the progress notes. If a CMT or Certified Nursing Assistant (CNA) obtained the BP, he/she would expect them to notify him/her immediately. During an interview on [DATE REDACTED] at 7:50 A.M., the Director of Nurses (DON) said she would have expected the CMT to hold any antihypertensive medication and tell the nurse immediately of the low BP. The nurse should check the BP, and if it is that low, then call the physician for any new orders. This should be documented in the resident's progress notes. She expects staff to follow facility policies.During an interview on [DATE REDACTED] at 9:35 A.M., RN F said that morning (9/17) the resident did not want to get up, which is unusual. He/She spoke to the resident who said he/she did not feel like getting up, but he/she said he/she felt fine. The CMT did not tell him/her the resident's BP was 78/67. The CMT should have told him/her. Had he/she known, he/she would have checked the resident's BP, and if it was that low, he/she would have ensured any antihypertension medications were held, and he/she would have called the physician. He/She would have documented any new order in the progress notes. During an

interview on [DATE REDACTED] at 12:13 P.M., the resident's physician and facility Medical Director said the CMT should have notified the charge nurse about the resident's BP of 78/67 and hold any antihypertension medications. If the CMT had notified the charge nurse, he would have expected the charge nurse to contact him. He would have ordered intravenous fluids, call emergency medical staff (EMS), and had sent the resident to the hospital for an evaluation. He is not sure had all of those things happened, that it would have changed the outcome for the resident. 2640283

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