Crescent Manor Care Ctrs

Inspectors wrotePer interview and record review, the facility failed to notify resident representative of alleged abuse of 1 of 1 residents (Resident #1).

Inspectors wroteBased on interviews and record reviews, the facility failed to support the residents' right to file grievances anonymously. This has the potential to affect all residents at the facility. Findings Include:Per observation, the facility's bulletin board in the lobby area displayed the grievance policy and procedure in a document protector, with only the first page visible. The document included the grievance officer and contact information, but did not provide details on how to file a grievance anonymously. There is no evidence of the option to file an anonymous grievance, nor is there any indication on the grievance forms that this is an option. Review of the facility policy, titled Crescent Manor Rehabilitation Grievance Policy and Procedures, no date, found that the procedures state the resident must sign the form. The form attached to the policy also requires a resident's signature. [...]

Inspectors wroteBased on observations, interviews, and policy reviews, the facility failed to store food in accordance with professional standards for food service safety. This deficiency has the potential to impact all residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe clean homelike environment for the residents who reside on the licensed memory care unit.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications were removed from the medication storage rooms and treatment rooms when expiration dates were reached for 3 out of 3 rooms.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff were appropriately wearing Personal Protective Equipment (PPE) for 2 of 2 units. This is a repeat deficiency for this facility, with violations cited during the previous recertification surveys, dated 10/2/24.

Inspectors wroteBased on observation and interview and record review, the facility failed to ensure a call system allowing residents to call for staff assistance is accessible to residents while in their bed or other sleeping accommodations within 5 out of 6 rooms for residents Care Planned for call bell use. The facility also failed to ensure that an alternate means of communicating with staff was provided after removing the call light from the resident's room for Resident #35.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the provider of laboratory results that fell outside of clinical reference ranges for 1 of 1 residents (Resident #27).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions to reflect an identified concern for 1 of 3 sampled residents (Resident #1) related to the use of wheelchair leg rests.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents remained as free from accidents as possible related to falls for 1 of 3 sampled residents (Resident #1) by failing to ensure assistive devices were provided and failing to implement interventions that would reduce the likelihood of future falls. As a result, Resident #1 suffered a fall that resulted in redness, swelling, and abrasions to the front of the left knee and back of the right hand.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 3 residents sampled [Resident #2].

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that 1 of 25 residents in the applicable sample (Resident #87) received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection. As a result, Resident #87's pressure ulcer worsened to stage four, developed an infection, the resident required hospitalized and surgical debridement of the wound, and was not stable enough to be discharged .

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and effective skin and wound care for 4 of 25 sampled residents (Residents #25, #30, #34, and #51) by failing to regularly and accurately perform and document weekly skin checks and non-pressure ulcer wound evaluations consistent with professional standards of practice. The facility also failed to ensure that a Resident with a wound vac received treatment and care in accordance with professional standards of practice and the person-centered care plan for 1 of 2 ( Resident # 291) of the applicable sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections related to the use of personal protective equipment for 3 of 12 residents on precautions (Residents #51, #25, and #30).

Inspectors wroteBased on staff interview and record review, the facility failed to ensure that all licensed nurses have the specific competencies and skill sets necessary to care for the resident's needs identified through resident assessments and the care plan for 2 of the 2 sampled residents (Resident # 291and Resident # 87).

Inspectors wroteBased on interviews and employee files, the facility failed to ensure that Licensed Nursing Assistants ( LNAs) received annual performance evaluations for 2 of the 2 LNAs employee files reviewed. Findings Include: Per review of employee files for LNAs who have worked at the facility for longer than a year, no nurse aide performance evaluations were completed within the past year. Per interview on 10/2/2024 at approximately 11:00, the Administrator confirmed that employee annual performance evaluations for the LNAs had not been completed.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident was assessed for injuries and complications in accordance with professional standards and per facility policy after sustaining a fall for 1 of 6 residents in the sample (Resident #1).

Inspectors wroteBased on interview, staff education record review, and the facility assessment, the facility failed to ensure that licensed nurses were assessed for competency and skill sets to provide care and respond to each resident's individualized needs. This has the potential to affect all residents. The facility assessment, last reviewed by the facility on 4/2023, states on page 11 that All staff attend general orientation as well as departmental training and associated competencies required for their position. Included in the list of staff competencies are Wound Care/Treatment Administration, and Specialized Care (ostomy care, catheter management/insertion, blood glucose testing, oxygen administration, dialysis care, tube feeding). [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one applicable resident (Resident #1).

Inspectors wroteBased on interview and record review, the facility failed to ensure that all known and foreseeable hazards in the resident's environment were eliminated and failed to provide sufficient supervision to each resident for 2 applicable residents (Resident #1 and #2) resulting in Resident #1 being physically abused.

Inspectors wroteBased upon interview and record review, the facility failed to provide routine and emergency drugs and biological's to its residents as ordered by a Physician for 3 residents [Res.#35, #42, & #43] of 26 sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident's care plan was updated after a change in condition with resident centered interventions that reflected the resident's current care needs for 1 of 22 residents included in the sample (Resident #2).

Inspectors wroteBased upon interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan for one resident [Res.#35] of 26 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities that are directed toward understanding, preventing, relieving, and/or accommodating a resident's loss of abilities for 1 of 6 sampled residents who reside on the locked special care unit (Resident #2).

Inspectors wroteBased on interview and record review the facility failed to ensure the physician documented a rationale for extending an as needed (PRN) order for a psychotropic drug for more than 14 days for 1 of 5 sampled residents (Resident # 56).