Crescent Health and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, homelike environment by failing to ensure an adequate amount of clean washcloths and towels to ensure that they available for all residents in the facility throughout the day.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure licensed nurses were knowledgeable, and competent in the disinfection of multi-residents shared glucometers in accordance with manufacturer's specifications. On 9/10/24 through 9/11/24, four licensed nurses on two different shifts and all three units of the facility were observed using multi-residents shared glucometers. The licensed nurses failed to disinfect the glucometers between each resident use. This failure placed 17 (Residents #82, #14, #11, #34, #4, #46, #21, #12, #49, #10, #59, #339, #27, #338, #41, #33, #54) of 17 residents requiring blood glucose testing at risk of exposure to blood-borne disease causing microorganisms which could result in serious illness or death of the residents. [...]

Inspectors wroteBased on observation, record review and staff interviews the facility failed to maintain an on-going infection prevention and control program by failing to ensure multi-residents shared glucometers (blood glucose meters) were properly disinfected between each resident use to prevent cross contamination and spread of infectious agents to 17 (Residents #82, #14, #11, #34, #4, #46, #21, #12, #49, #10, #59, #339, #27, #338, #41, #33, #54) of 17 residents requiring blood glucose testing. On 9/10/24 through 9/11/24 a total of four licensed nurses on different shifts and units were observed using multi-residents shared glucometers. The nurses failed to disinfect the glucometers between each resident use. [...]

Inspectors wroteBased on observation and interview the Facility failed to ensure a clean and sanitary environment by failing to ensure the carpets in the halls of the facility and several rooms in the facility (rooms 616, and 610) were clean and sanitized, failing to ensure the walls were free form streaks, gouges and pealing wallpaper (rooms 616, 614, 610, and 609) the privacy curtains in room [ROOM NUMBER] and 610 were free from stains, The roof was in good repair and the ceiling in room [ROOM NUMBER] was free from signs of leaking, also, the hand rails were free from worn areas, and the hand rails were free from dirt and debris throughout the facility.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to implement physician's ordered interventions to prevent the development of avoidable pressure ulcers for 1 (Resident #34) of 5 sampled residents identified at risk for development of pressure ulcers.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to ensure staff followed safety precautions to prevent avoidable falls and accidents for 1 (Resident #34) of 5 dependent residents observed during transfer with a full body mechanical lift.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure its medication error rate was below 5%. Five nurses, seven residents and 25 opportunities were observed. Three medication errors were identified resulting in a medication error rate of 12%.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure 7 (Residents #2, #1, #3, #5, #12, #8, and #10) of 7 residents interviewed were provided meals at regular times comparable to normal mealtimes in the community.

Inspectors wroteBased on observation and interview, the facility failed to ensure sufficient qualified nursing staff to meet residents' needs in a timely manner for 2 (Residents #3, and #4) of 5 residents interviewed.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medications were not left unattended and remained under the direct observation of the person administering the medications for 2 (Residents #2 and #3) of 2 residents with medications observed unsecured at bedside.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that the clinical record was accurately documented for 1 (Residents #2) of 2 residents observed with unsecured and unattended medications at bedside.

Inspectors wroteBased on observation, clinical record review, and staff interviews the facility failed to ensure staff consistently implemented individualized interventions to meet the needs and prevent avoidable accidents for 1 (Resident #41) of 4 sampled residents reviewed for falls.

Inspectors wroteBased on observation, facility policy review, resident and staff interviews, the facility failed to maintain proper medication storage for 1 (Resident #82) of 1 resident observed with unsecured, unlabeled medication at the bedside. The facility failed to properly label opened medication in 1 ([NAME] medication cart) of 3 medication carts reviewed.

Inspectors wroteBased on interview and maintenance review, the facility failed to have documentation of maintenance of resident care equipment to ensure safe operating condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate documentation of advance directives for 1 (Resident #65) of 6 residents reviewed for advanced directives.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications for 2 (Residents #47 and #78) of 5 residents reviewed for medication storage.

Inspectors wroteBased on record review, and interview, the facility failed to maintain accurate meal consumption documentation for 1 (Resident #45) of 3 ensure residents reviewed for nutritional intake.

Inspectors wroteBased on observation and interview, the facility failed to provide a sanitary environment for 2 residents (Resident #47 and Resident #78) of 5 residents reviewed for sanitary environment. On 4/26/21 at 12:16 p.m., during a tour of the facility, an uncovered, unlabeled urinal was observed on the back of the toilet of room [ROOM NUMBER] which was a double occupancy room. Two uncovered, unlabeled toothbrushes, sitting in cups of water were also observed on the bathroom counter. The same observation was made on 4/27/21 at 9:12 a.m. and 4/27/21 at 11:01 a.m. On 4/28/21 at 10:14 a.m., observed the two toothbrushes remained uncovered and unlabeled on the counter of the double occupancy room [ROOM NUMBER]. On 4/28/21 at 10:44 a.m., Unit Manager Staff E went into room [ROOM NUMBER] and confirmed the items were not labeled or stored properly. [...]