Crescent Cities Nursing & Rehabilitation Center

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to ensure that residents were served meals according to predetermined menus. This was evident for 4 (Residents #92, #34, #121 and #48) of 6 random meal trays sampled during the lunch tray line observation.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to maintain the ice machines in a clean and sanitary manner. This was evident in 2 of 5 ice machines inspected during the recertification survey. This practice has the potential to affect all residents who consume food prepared by the facility.

Inspectors wroteBased on facility documentation and interviews, the facility failed to have an Infection Preventionist (IP) onsite. Failure to have an Infection Preventionist has the potential to decrease compliance with infection control.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide documented evidence that all residents and/or representatives received written information concerning the right to accept or refuse medical or surgical treatment and the option to formulate an Advance Directive (AD). This is true for 1 (Resident #166) of 4 resident records reviewed for advanced directives during the recertification survey process. Findings Included:On 02/25/2026 at 12:22 PM, the Social Worker (SW) explained the AD process, stating ADs were to be uploaded to the electronic health record upon admission. If not available, the AD was discussed during the Discharge Planning Psychosocial Assessment. The SW noted that while the assessment form included a question about offering information for initiating an AD, the form may not have been accurately, checked, or completed. [...]

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident. This was evident for 1 (Resident #32) of 68 resident care plans reviewed during the recertification survey process. Findings Included:On 02/26/2026 at 2:21 PM, a review of Resident #32's Medication Administration Records (MAR) showed an order dated 01/29/2026 for cefTRIAXone Sodium Injection Solution Reconstituted 2 gram (Ceftriaxone Sodium), once daily for a 5-day course to treat a bacterial infection. On 02/27/2026 at 2:49 PM, a review of Resident #32's care plan revealed the facility failed to develop and implement a comprehensive person-centered care plan to address the resident's infectious disease process and antibiotic treatment needs. [...]

Inspectors wroteBased on record reviews, observations, and interviews, it was determined that the facility failed to ensure staff used a functional communication system to communicate personal care needs for a non-English speaking resident. This was evidenced by findings for 1 (Resident #172) of 1 resident reviewed for communication and language services during the recertification/complaint survey. Findings Included:A care plan is a tool used to summarize the resident's healthcare needs, treatments, and care goals. This tool is to be developed within 7 days after completion of the comprehensive assessment and prepared by an interdisciplinary team. On 02/24/2026 at 12:00 PM, during the initial pool phase of the annual survey process, Resident #172 (who was non-English speaking) called out to the surveyor, pointed to the perineal area. [...]

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to provide an adequate smoking evaluation and safety assessment for a resident. This deficiency was evident for one (Resident #39) of two residents reviewed for safety in smoking during the recertification/complaint survey.

Inspectors wroteBased on medical record reviews and staff interviews, it was determined that the facility failed to timely address and communicate significant weight changes. This deficiency was evident for two (Resident #11 and Resident #143) of six residents reviewed for nutrition during the recertification/complaint survey.

Inspectors wroteBased on observation, record review, and staff interviews, it was determined that the facility failed to provide necessary respiratory care services. This was evident for 3 (Residents #1, #3 and #171) of 6 residents reviewed for respiratory care during the recertification survey.

Inspectors wroteBased on a review of employee files and interviews with facility staff, it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNAs) demonstrated competency in essential skills and techniques prior to providing resident care. This deficiency was identified in four out of four (Staff #11, #12, #13, and #14) newly hired GNA employee charts reviewed during the recertification/complaint survey.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to identify and provide appropriate treatment and services to assist a resident in attaining their highest practicable mental health well-being. This deficiency was evident for one of one resident (Resident #111) reviewed for behavioral and emotional well-being during the recertification/complaint survey.

Inspectors wroteBased on review of medical record and interview with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was true for 3 (Residents #171, #3 and #116) of 5 residents reviewed for unnecessary medications during the recertification survey.

Inspectors wroteBased on record reviews, observations and interviews, it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 2 of 26 medication administration opportunities which resulted in an error rate of 7.69%. Findings Included:A Percutaneous Endoscopic Gastrostomy (PEG) tube is the placement of a flexible gastric tube into the stomach. On 02/27/2026 at 10:55 AM, the surveyor observed Licensed Practical Nurse (LPN) #31 administering medications to Resident #87. LPN #31 crushed and administered acetaminophen 500mg via a gastric feeding tube. On 02/27/2026 at approximately 11:00 AM the surveyor reviewed Resident #87's medication orders and Medication administration records which revealed an order for acetaminophen 325mg Oral 2 tablets. [...]

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to ensure that medication was stored in a locked compartments under proper temperature controls. This was true for Resident#172's room observed during the initial tour of the facility.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure food was delivered to residents at an appropriate and palatable temperature. This was evident for 1 of 1 test tray temperature observation.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to ensure a therapeutic diet was prescribed for a resident. This deficiency affected one (Resident #57) of three residents reviewed for dietary services during the recertification/complaint survey.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure staff donned appropriate personal protective equipment (PPE) for enhanced barrier precautions as required. This is evident for 1(Resident #87) of 7 Residents observed for medication administration during the facility task portion of the survey process. Findings Included:Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) (CDC website 2025). [...]

Inspectors wroteBased on complaint and a facility report incident, reviews of a closed and active medical record and all pertinent administrative records, and staff interview, it was determined that the facility staff failed to 1) follow physician orders to obtain weights, and 2) provide care to a resident when a staff member called out during the day shift on 01/12/2025. This was evident for 3 (Residents #19, #1, #21) out of 30 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, reviews of closed and active medical records, reviews of the facility enteral feeding tube policy, and staff interview, it was determined that the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding. This was evident for 5 (Residents #19, # 25, #26, #27, #28) of 30 residents reviewed for tube feeding during a complaint survey.

Inspectors wroteBased on reviews of a complaint, a closed medical record, and interview with facility staff, it was determined that the facility failed to notify a resident's representative of 1) the risk and benefits of a surgical procedure and 2) to seek permission to perform the surgical procedure. This was evident for 1 (Resident #25) of 30 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of a complaint, a closed medical record and a patient fund account, and interviews with facility staff, it was determined that the facility staff failed to disperse the remaining account funds to a discharged resident (Resident #23) within 30 days. This is evident for 1 of 30 residents reviewed during compliant survey.

Inspectors wroteBased on reviews of a complaint, a closed medical record, and all pertinent administrative records and staff interview, it was determined that the facility staff failed to immediately notify a resident's physician and responsible party regarding a change in condition on 07/06/25 at 3 AM. This was evident for 1 (Resident #15) of 30 residents reviewed during a complaint survey.

Inspectors wroteBased upon complaint, reviews of a closed medical record and all other pertinent administrative documents, and staff interview, it was determined that facility staff failed to ensure that incidents of injuries of unknown source were reported to the State Agency (OHCQ) in a timely manner. This was evident for 2 (Resident # 15, #25) of 30 residents reviewed during a complaint survey.

Inspectors wroteBased on reviews of a complaint, a resident's closed medical records, and staff interviews, it was determined that the facility staff failed to provide activities of daily living (ADL) care in accordance with the resident's plan of care. This was found to be evident for 1 (Resident #25) of 30 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by crushing a medication that should not be crushed. This was evident for 2 (Residents #19, #7) of 30 residents reviewed during a complaint survey.

Inspectors wroteBased on complaints, reviews of a closed medical record and staff interview, it was determined that the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for ?????? (Residents #15) of 30 residents reviewed during a complaint survey.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 44) reviewed for safe transfers from a total sample of 39 was safe during a transfer that required a mechanical lift. This failure caused R44 to have a right femur fracture. Upon identification of the fracture, the facility failed to report the fracture, failed to conduct a root cause analysis of the fracture, and failed to ensure staff were provided education on proper mechanical lift transfers. R44 reported to Geriatric Nursing Assistant (GNA) 1 on an unknown date that she was afraid of the Hoyer lift because of a previous incident. GNA1 reported this information to the nurse on duty (Licensed Practical Nurse (LPN) 1). It was reported that LPN1 assessed R44 at the time; however, there was no documentation of the assessment. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one of 39 sampled residents (Resident (R) 23) was treated with dignity and respect during meals. Specifically, staff stood over the R23 while assisting the resident with eating, staff did not offer R23 an alternate for lunch when the resident continued to spit out his/her food, and staff failed to remove a large tube of A&D Medicated Ointment (used during incontinent care to treat rashes and protect the skin) off of R23's bedside table prior to placing his/her meal tray on the table.

Inspectors wroteBased on observation, interview, record review, review of Resident Council Minutes, and facility policy review, the facility failed to serve food that was palatable for five of five residents (Resident (R) 29, R35, R48, R55, and R133) reviewed for food palatability out of 39 sampled residents. This failure had the potential to cause unmet nutritional needs for 145 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on a complaint, medical record review and interview with facility staff, it was determined that the facility failed to provide and review admission agreement with the appropriate resident or representative (RP). This was evident for 2 of 39 (#813 and #830) residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to ensure that the correct person was identified to make medical treatment decisions on the Maryland Order for Life Sustaining Treatment (MOLST) form. This was evident during the review of 1 of 3 (#818) MOLST forms, reviewed during a recertification/complaint survey.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure an injury of unknown origin was reported within two hours and investigative results were reported within five working days to the State Survey Agency (SSA) for one of nine residents (Resident (R) 18) reviewed for abuse out of a total sample of 39, and for 1 (Resident #807) of 16 facility reports reviewed for abuse during the recertification/complaint survey.

Inspectors wroteBased on record review, interview, review of Facility Reported Incidents (FRI), and facility policy review, the facility failed to ensure an injury of unknown origin was thoroughly investigated for 2 residents (Resident (R) 18, #12) out of 39 reviewed during a recertification/complaint survey. There was no evidence that the facility interviewed other current residents regarding the allegation. This failure had the potential to place all residents at risk of continued abuse.

Inspectors wroteBased on record review and interview it was determined that the facility failed to permit a resident to stay in their facility. This was evident for 1 (#810) of 2 residents reviewed for discharge complaints during the recertification/complaint survey.

Inspectors wroteBased on record review and staff interview it was determined the facility failed to issue a 30-day transfer notice to a resident prior to transferring them to another facility. This was evident for 1 (#810) of 2 residents reviewed for discharge during a recertification/complaint survey.

Inspectors wroteBased on record review and staff interview it was determined that the facility failed to provide discharge planning for a resident. This was evident for 1 (#829) of 2 residents reviewed for discharges during a recertification/complaint survey.

Inspectors wroteBased on record review and interview it was determined the facility staff failed to ensure each resident received treatment and care in accordance with professional standards of practice by failing to 1) obtain a dental consult, 2) monitor resident behaviors as ordered by the physician, and 3) obtain a resident's stool sample and send the stool sample for laboratory analysis (#806). This was evident for 2 (#807 and #806) of 16 reports reviewed for abuse during a recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to provide adequate monitoring of a resident's pain (R#12) resulting in the resident receiving delayed treatment for a fractured right ankle. This was evident for 1 of 39 residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate of less than five percent. During observations of medication pass, there were three errors observed out of 31 opportunities, resulting in a 9.68% error rate. This had the potential to place two residents (Resident (R) 13 and R114) at risk of not receiving the full benefit of their medication therapy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to offer alternate meals for one of 39 (Resident (R) 23) sampled residents observed during meal time. R23, a severely cognitively impaired resident, showed signs she did not like the meal served but staff did not offer a substitute without prompting. This had the potential to have a negative impact on R23's nutritional status.

Inspectors wroteBased on medical record review and interview, the facility staff failed to follow up with outside resources for the care of residents (Resident #820). This was evident for 1 of 4 residents reviewed during a recertification/complaint survey for ordered appointments or services not rendered inside the facility.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to maintain complete and accurate medical records in accordance with acceptable professional standards. This was evident for 1 (Resident #513) out of 33 resident records reviewed during the revisit survey.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) while providing wound care for one of one resident (Resident (R) 204) reviewed on Enhanced Barrier Precautions (EBP) out of a total sample of 39. This failure increased the risk of spreading multi-drug-resistant organisms throughout the facility. In addition, the facility failed to ensure that one of six residents (R82) observed during medication administration was given medication in a manner to prevent possible cross-contamination. This failure had the potential to place R82 at risk for infection.

Inspectors wroteBased on document review and staff interview, the facility failed to ensure the Facility Assessment was updated annually, names of facility leadership had been updated to reflect current staff, and accurate and current resident assessments were included to ensure the facility provided services that meet the needs of the current residents. Specifically, the Facility Assessment most recent update was 02/06/23, did not list current staff names, and resident data was not accurate as it reflected Minimum Data Set (MDS) data from 01/01/22 - 01/30/22. This failure could negatively impact 151 of 151 residents by not assessing and determining the current needs of the residents.

Inspectors wroteBased on observations during an environmental tour and staff interviews, it was determined that the facility's staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 6 of 37 residents observed during the survey process (Residents #20, #25, #36, #53, #59, and #66).

Inspectors wroteBased on the review of residents' medical records and an interview with a resident, it was determined that the facility failed to 1. develop a care plan for 1 of 2 residents reviewed for urinary catheters (Resident #45), 2. develop a care plan for 1 of 2 residents reviewed for tube feedings (Resident #108), and 3. develop a care plan for 1 of 1 residents reviewed for sensory deficits (Resident #10).

Inspectors wroteBased on observation, medical record review, and staff interviews, it was determined the facility failed to provide the appropriate level of assistance and services for 3 of 30 residents that require assistance with activities of daily living (ADLs) (Residents #65, 20, and #17).

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to provide evidence that all nursing staff had received competency evaluations. This was evident for 3 of 4 employee selected for review during the survey (Staff #13, #14, and #15) and all nursing staff hired prior to 6/15/19.

Inspectors wroteBased on record reviews, interviews with the facility's staff, a review of the facility's infection control polices and observations, it was determined that the facility failed to: 1. follow acceptable infection control practices, 2. maintain the laundry area in a manner to ensure clean [NAME] and prevent or control the spread of infection, and 2) ensure that food service was provided to residents in a sanitary manner as evidenced by mobile food carts not having proper food protection in the form of sneeze guards on three of the sides. This was evident for 2 out of 3 residents reviewed for isolation precautions (#104, #109) and for 3 of 3 mobile food carts observed in the facility's kitchen. Clostridium difficile (C.diff) is a bacterium that causes diarrhea and colitis (an inflammation of the colon). It is estimated to cause almost half a million illnesses in the United States each year. [...]

Inspectors wroteBased on observations of the facility and staff interview, it was determined that the facility's nursing staff failed to ensure confidentiality of residents' medical record was maintained on the third floor nursing unit. This was evident on 2 out of 10 medication carts, one resident (Resident #52) with an order for blood pressure medication, and all residents on the unit with a prescription for a narcotic medication.

Inspectors wroteBased on medical records review, it was determined that the facility's staff failed to ensure information used to complete the quarterly Minimum Data Set (MDS) assessment for medication use was accurate and complete. This was evident for 1 of 57 residents selected for medical record review during annual survey process (Resident #122).

Inspectors wroteBased on a record review, it was determined that the facility failed to develop a baseline care plan for the use of an antipsychotic medication for 1 of 1 resident reviewed for unnecessary medication (Resident #81).

Inspectors wroteBased on record review and staff interview it was determined the facility failed to provide evidence that all nursing staff received education in behavioral health. This was evident for 1 of 4 employee records reviewed during the survey (Resident #12) and and all nursing staff hired prior to 6/15/19.

Inspectors wroteBased on record review and staff interview it was determined the facility failed to provide evidence that all nursing staff had received education on abuse prevention. This was evident for 1 of 4 employee records reviewed during the survey (Staff #12).