Crossroads Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three of seven residents (Resident # 1, Resident #2, and Resident #3) reviewed for activities. The facility failed to provide Resident #1, Resident #2 and Resident #3 in room activities three times per week, as care planned, during the months of March 2026 and April 2026. This failure could place residents at risk for boredom, depression, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three of five residents ( Resident # 5, Resident # 45 and Resident #46) reviewed for activities. The facility failed to provide Resident #5, Resident #45, and Resident #46 in room activities three to five times per week during the months of October 2025 and November 2025. This failure could place residents at risk for boredom, depression, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 12.9% based on 4 out of 31 opportunities, which involved 1 of 4 residents (Resident #13) and 1 of 2 MAs (MA D) observed during medication administration reviewed for medication error. 1. The facility failed to ensure MA D failed to administer Resident #13's physician ordered medications acidophilus lactobacillus and artificial tears. 2. The facility failed to ensure MA D failed to administer Resident #13's B12 vitamin as ordered by the physician. 3. The facility failed to ensure MA D did not administer Resident #13 a multivitamin tablet without a physician order. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food under sanitary conditions in accordance with professional standards for food service safety for one of one kitchen. The facility failed to ensure Dietary Aide A and Dietary [NAME] B used proper hand hygiene during food preparation on 12/03/2025. This failure could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents reviewed for infection control practices. A) The facility failed to ensure the ADON used aseptic technique during wound care for Resident #16By not cleaning the wound care supplies prior to treatment, not setting up the clean field per facility policy, not performing hand hygiene or glove changes at all appropriate opportunities not performing hand hygiene or glove changes between wounds, and not re-cleaning the wounds after they were contaminated during the treatment. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 4 residents reviewed for accommodation of needs (Resident #33 and Resident #45. A) The facility failed to follow their facility policies and procedures and provide full time translation or interpretation services to Resident #33, a Spanish speaking resident. B) The facility failed to ensure Resident #45 specialty wheelchair was in safe working order so he could safely get out of bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #33) of five residents reviewed for care plans, in that:1. The facility failed to complete a person-centered care plan for Resident #33's primary language as a Spanish . 2. The facility failed develop a care plan for Resident #33's refusals to take showers (refusal timeline unknown). This failure placed residents at risk of unaddressed needs, fragmented care, emotional distress (anxiety, depression), poor health outcomes, and a loss of dignity/autonomy, leading to a lower quality of care and not receiving goals and interventions for the residents' individual needs for person-centered care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident #27 and Resident #39) reviewed for ADL care. The facility failed to ensure Resident #27 and Resident # 39's nails were cleaned and trimmed on 12/04/2025. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage of medications used in the facility in accordance with currently accepted professional principles for 1 of 3 medication carts reviewed. The facility failed to ensure potential contaminants, including personal items, were not on the medication carts. This failure could place residents at risk of receiving contaminated medications resulting in adverse health consequences.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident representative when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 5 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's responsible party after Resident #1 experienced an unwitnessed fall on 08/12/2025 that resulted in an abrasion. This deficient practice could place residents at risk of not having their responsible party notified of changes, resulting in a delay in medical intervention and decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to develop, and implement a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Residents #1) reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan updated interventions after Resident #1 experienced multiple falls. This deficient practice placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical, mental and/or psychosocial well-being.

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for falls. The facility failed to develop and implement individualized interventions for Resident #1 after the resident experienced multiple falls. This failure placed residents with falls at risk of injury, pain, bruises, fractures, dislocation of joints, and/or significant changes in condition.

Inspectors wroteBased on interviews and record reviews the facility failed to implement a comprehensive person-centered care plan for one (1) resident (Resident #1) of six (6) residents reviewed for care plans. The facility failed to ensure Resident #1 care plan was updated and revised after behavior events on 11/2/2024 and 11/7/2024, causing Resident #1 injuries to her face on 11/7/2024. This failure placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury and a decline in physical well-being for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two of five (Resident #7 and Resident #47) residents reviewed for dignity. 1. The facility failed to ensure Resident #7 had a privacy cover on their urinary catheter bag. 2. The facility failed to ensure Resident #47 was served lunch at the same time as the other residents at her table for two days. These failures could affect the resident's dignity and affect their quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately inform the resident's Physician when the nurse was unable to follow wound care orders for one of one Residents (Resident #49) reviewed for physician notification of changes. The facility failed to ensure RN C notified the Physician and family of her inability to follow wound care orders for Resident #49. This failure could have delayed the progress of the coccyx wound healing for Resident #49.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #49) of two residents reviewed for pressure injuries. The facility failed to ensure RN C followed Physician's orders for wound care for Resident #49. The facility failed to ensure RN C documented the wound care she provided for Resident #49 without a Physician order. These failures could have delayed the progress of the coccyx wound healing for Resident #49.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of one Residents (Resident #49) reviewed for pressure ulcers wound care. The facility failed to ensure RN A followed standard precautions during wound care for Resident #49's Stage 4 coccyx pressure ulcer when she contaminated supplies prior to wound care and used contaminated scissors to cut foam used for wound care which she then placed into the open wound. This failure could place residents at risk for developing wound infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 2 (Resident #1 and Resident #2) of 4 residents reviewed for respiratory care. The facility failed to ensure that Resident #1's oxygen tubing with nasal cannula and humidifier bottle was replaced every seven (7) days. The facility failed to ensure that Resident #1's air concentrator filter was cleaned and free of dust and debris particles. The facility failed to ensure that Resident #2's Nebulizer tubing and mask, which included the nebulizing chamber (unit into which liquid medicine is converted into aerosol or mist by the pressurized air pumped through the tubing), was replaced every seven (7) days. These failures could place residents at risk for respiratory compromise and infection. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (Resident #1, Resident #2, and Resident #3) of 5 residents reviewed for medication/treatment errors. The facility failed to follow physician's orders for providing wound care to Resident #1, Resident #2, and Resident #3, on a regular basis. This failure could place residents at risk of delay in wound infection and healing process. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 1 of 1 resident (Resident #3) reviewed for privacy. The facility failed to ensure DON, RN A and CNA A provided privacy by closing the privacy curtain during wound care for Resident #3. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life.

Inspectors wroteBased on observation, interviews and record review the facility failed to develop and implement a comprehensive person care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one of five residents reviewed for care plans. (Resident #1). The facility failed to develop and implement a person-centered care plan for Residents #1. This deficient practice placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury and a decline in physical well-being Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents and hazards. The facility failed to ensure Resident #1's new intervention of a fall mat was placed on the right side of bed when Resident #1 was lying in bed. This failure could result in residents experiencing accidents, injuries, unrelieved pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote resident self-determination through support of family choice for 1 of 17 residents reviewed for resident rights. (Resident #33) The facility did not assist Resident #33 out of bed when family requested. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 3 of 20 residents reviewed for care plans. (Resident #51, Resident #28, and Resident #33) The facility failed to develop a comprehensive person-centered care plan including an active problem of bowel and bladder incontinence, oxygen usage, and risk for malnutrition for Resident #51. The facility failed to develop a comprehensive person-centered care plan including an active problem of pain, use of foley catheter, use of diuretics, use of opioid medications, and need for assistance with ADLs for Resident #28. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for 5 of 24 residents (Resident #50, Resident #21, Resident #10, Resident #29, and Resident #18). The facility failed to follow the menu. The facility failed to update residents' meal tickets to match what they were served. These failures could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate MDS assessment was completed for 1 of 14 residents reviewed for MDS accuracy. (Resident #26) The facility failed to document visual impairment and anti-anxiety use on the MDS for Resident #26. These failures could place residents at risk for not receiving needed care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care for 2 of 17 residents reviewed for baseline care plans. (Resident #49 and Resident #54) The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #49. The facility failed to develop a complete baseline care plan for Resident #54. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 16 residents reviewed for ADLs (Residents #25.) The facility did not clean or trim Resident #25's fingernails. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 of 17 residents reviewed for vision services, received proper treatment and assistive devices to maintain vision abilities. (Resident #33) The facility did not address Resident #33's need for a vision exam. This failure could affect residents by causing them to have decreased vision awareness when ambulating, difficulty seeing and participating in activities, and decreased self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 4 residents reviewed for respiratory care. (Resident #15 and Resident #51). 1. The facility failed to ensure Resident #15's oxygen concentrator had a filter in place to change weekly per physician orders. 2. The facility failed to ensure Resident #51's nasal cannula was sanitarily stored when not in use. These failures could place residents at risk of respiratory infections.