Eagle Crest Rapid Recovery

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 7 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA A did not verbally and emotionally abuse Resident #1 when speaking rudely to Resident #1 on 02/24/2026. The facility failed to ensure Resident #1's resident's right to be treated with dignity and respect on 02/18/2026, when CNA A spoke rudely to Resident #1. This failure could place residents at risk of abuse, and mental anguish and fearfulness. The noncompliance was identified as past noncompliance (PNC) and began on 02/18/2024 and ended on 02/23/2026. The facility corrected the noncompliance before the investigation began on 04/02/2026 at 08:30 a.m.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change for 1 of 3 residents (Resident #1) reviewed for notification of changes. The facility failed to notify MD of Resident #1 abuse allegation. This failure placed residents at risk for potential injuries, pain, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 (Resident #1) of 5 residents reviewed for personal hygiene. CNA A did not provide incontinent care for Resident # 1 for over 4 hours. This failure could place residents at risk for infection and impaired skin integrity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for 1 (Resident #1) of 5 residents reviewed for incontinence. CNA A did not provide incontinent care for Resident # 1 for over 4 hours. CNA A did not clean Resident #1 in the right direction (front to back) instead, CNA A cleaned Resident #1 from back to front during incontinent care. This failure could place residents at risk for infection and impaired skin integrity.

Inspectors wroteBased on interviews and record reviews, the facility did not ensure that the resident's requests, refusals, discontinuations, and advance directives were honored for 1 of 1 (CR#1) resident's DNR. LVN A provided CPR to CR #1 prior to determining if the resident had advanced directives in place resulting in CR #1 receiving life-saving intervention from LVN A and then emergency responders. Emergency responders did restore CR #1's pulse and CR#1 was transported to the hospital where CR#1 expired. The noncompliance was identified as Past Non-Compliance. The IJ began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. This deficient practice could place residents at risk of harm and injury due to inadequate care.

Inspectors wroteBased on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental, and mental and psychosocial needs that were identified in the comprehensive assessment for 6 of 7 residents (Residents #4, #41, #30, #1 #37 and #62) reviewed for care plans. 1. The facility failed to develop and implement a plan of care that addressed the prevention of facility acquired pressure ulcers/injury . 2. The facility failed to develop a plan of care for the continuous use of heel protectors for Residents #4, #41, #1 and #37 who developed facility acquired pressure ulcers/injuries to their feet. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 5 of 7 (Residents #4, #41, #30, #1 and #37) residents reviewed for pressure ulcers.- The facility failed to turn and reposition Resident #4 every 2 hours and failed to identify skin issues during CNA skin monitoring during showers and nurse skin assessments. Resident #4 developed an in-house stage 4 pressure to his heel without any previously documented skin concern. - The facility failed to ensure Resident #4's low-air-loss mattress was in use as ordered by his physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 8 residents (Resident #82) reviewed for pain management. - The facility failed to continuously assess Resident #82's pain for more than 24 hours after her admission on [DATE]. This failure could place residents at risk for decreased quality of life, uncontrolled, irretractable pain, and hospitalization. Findings Include: Record review of Resident #82's Face Sheet, dated 08/06/25, revealed an [AGE] year-old female, admitted to the facility from a private home for hospice-respite services, with diagnoses of: Alzheimer's Disease, protein-calorie malnutrition. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and ensure it had a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that drug records were in order and an account of all controlled drugs was maintained and periodically reconciled for 1 of 3 (200 Hall Medication Cart) medication carts and 5 of 8 residents (Resident #49, Resident #69, Resident #71, Resident #75 and Resident #82) reviewed for pharmacy services. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 8 resident (Resident #26 and Resident #62) reviewed for accuracy of assessments. - The facility failed to ensure Resident #26's admission MDS, dated [DATE], accurately reflected the residents use of opioid pain medication, Oxycodone,. - The facility failed to ensure Resident #62's Annual MDS, dated [DATE], accurately reflected the residents significant weight loss of 12.7% over a 6-month period from 01/15/25 to 07/08/25 dated. These failures could place residents at risk of inaccurate assessments, which could compromise their plan of care .

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 9%, based on 3 errors out of 32 opportunities, which involved 2 of 7 residents (Resident #48 and Resident #56) and 1 of 3 staff (LVN M) reviewed for medication errors.- LVN M failed to accurately administer medication to Resident #48 by crushing extended release Mucinex (a medication used for phlegm and congestion).- LVN M failed to accurately administer medications to Resident #56 by failing to administer the resident's Lexapro 5 mg (used to treat depression) and attempting to administer 10 ml of seizure medication (Levetiracetam) instead of 7.5 ml as ordered by the resident's physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for 4 of 11 residents (Residents #2, #8, #19, and #65) reviewed for significant medication errors. - The facility failed to ensure nursing staff administered pre-prandial (before a meal) insulin to Resident #2, Resident #8, Resident #19, and Resident #65 safely by administering it more than 30 minutes before meals. This failure could place residents at risk of uncontrolled blood sugars, hypoglycemia (low blood sugars), hyperglycemia (high blood sugars) and worsening of diabetes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 3 medication carts ( 500/600/700 Hall Medication aide Cart, 200 Hall Nursing Care) and 1 of 1 (500/600 Hall Med Room) Medication Rooms reviewed for medication storage. [...]

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 3of 5 residents (Residents #37, Resident #48 and Resident #56) reviewed for infection control practices.-PT E failed to follow proper infection control and hand hygiene after providing wound care to Resident #37. - -PT E failed to perform hand hygiene prior to leaving the resident's room.-CNA N failed to follow proper infection control practices by washing hands in the clean utility room after handling dirty trash bags.- LVN M failed to wear the appropriate PPE when administering medications via G-tube to Resident #56. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was a significant change in condition in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly for 1 of 8 residents (Resident #11) reviewed for notification of changes. The facility failed to notify the physician of Resident #11's reported chest pain and SOB which resulted in the discontinuation of her PT session on 08/08/25. This failure could place residents at risk of delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, and suffering.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care that met professional standards of quality of care for one of 8 residents (Resident #82) reviewed for base line care plans. The facility failed to develop and implement a baseline plan of care that addressed Resident #82 who admitted to the facility for 5 days of respite care ( a short term stay in a nursing facility that provides temporary relief for caregivers of individuals needing assistance, allowing them to take a break from their caregiving duties) needs for the administration of morphine for her pain, and behaviors that became so severe she required administration of ABH gel. [...]

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 1 of 8 residents (Resident #43) reviewed for ADL care. The facility failed to provide nail care to Resident #43, leaving the resident with fingernails approximately 1/2 inch longer than the nail bed and his toenails were long with some curling around the tip of his toes.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents (Resident #25) reviewed for quality of care. - The facility failed to provide wound care to Resident #26 on 08/03/25. This failure could place residents at risk of worsening of wounds, infection and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 Resident (Resident #56) reviewed for enteral nutrition.- LVN M failed to administer medications and enteral feed safely to Resident #56 by: initiating medication administration without first checking for G-tube (a tube inserted through the abdominal wall into the stomach for the administration of medication and food) placement,; administering a bolus feed immediately following medication administration of 7 medications,; and forcefully pushing medication and the bolus feed through a connected syringe instead of gravity. These failures could place residents at risk of injuries, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to update and post the daily nursing staffing information on Saturday 06/28/25, Sunday 06/29/25, Monday 06/30/25 and at the beginning of the 1st shift on 07/01/25. The last revision was made on 06/27/25. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include:An observation on 07/01/25 at 07:51 to 08:00AM revealed, the facility Daily Nurse Staffing Report posting on the top of a pony wall located in front of the receptionist desk that read Date: 06-27-25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 1 of 7 Residents (Resident #12) reviewed for medication storage. LVN A left Resident #12's insulin unattended at her bedside. The failure could place residents at risk for possible drug diversions or accidental ingestion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (Resident #1) of six residents whose records were reviewed for falls in that: Resident #1 rolled off the bed during incontinent care with x1 assistance. This failure could place fall risk residents at risk for harm and serious injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to properly inspect the Hoyer Lift slings, resulting in it tearing and causing the resident to have a fall and sustain a bruise to her left shoulder. Resident #1's fall caused pain at a level 9. -The facility failed to properly train the staff on how to report concerns and determine properly Hoyer sling sizes. An Immediate Jeopardy (IJ) was identified on 10/09/2023 at 6:35 PM. The IJ template was provided to the facility on [DATE] at (6:35PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 5 residents (Resident #1) reviewed for pain management, in that; Resident #1 experienced pain after a fall on 10/06/2023 and the pain was not reported to the NP until 10/09/2023. The facility failed to contacted the NP or Physician after the fall when Resident #1's pain level increased to a level 9, resulting in an increase PRN pain medications. These failures affected one resident who was placed at risk of pain, bruising, and increased use of PRN pain medication. An Immediate Jeopardy (IJ) was identified on 10/09/2023 at 6:35 PM. The IJ template was provided to the facility on [DATE] at (6:35PM. [...]

Inspectors wroteBased on observation interview and record review, the facility failed to develop a comprehensive care plan for 1 of 18 (Resident #4) reviewed for care plans, in that: Resident #4 did not have a care plan for ADL care and pressure ulcer risk. This failure could place residents at risk of potentially not having their needs for care identified and tended to.

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise the comprehensive person-centered care plan that included measurable objectives to provide individualized care for 1 of 18 residents reviewed for care plan accuracy (Resident # 12). ---Resident #12 had a care plan for IV antibiotics (drugs given through a needle into a vein) for Pneumonia. Resident has since recovered from Pneumonia and IV antibiotics have been finished and discontinued. This failure placed residents at risk of having inaccurate comprehensive care plans and not receiving proper individualized care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 1 of 7 residents (Resident #16) reviewed for professional standards. The facility failed to ensure an active physician's order was in place prior to administering Lorazepam 0.5mg tablet to Resident #16 This failure could place residents at risk of inadequate care, possible adverse drug reaction or hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 7 residents (Resident #16) reviewed for medications in that: -The facility administered expired Lorazepam 0.5mg tablet to Resident #16 This failure could place residents receiving medications at risk of not receiving therapeutic levels from the medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used were labeled in accordance with currently accepted professional principles, which included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 6 carts (400 Hall Nursing Cart) reviewed for medication storage. The facility failed to ensue 400 Hall Nursing Cart did not contain an insulin pen without a resident identifier. This failure could place residents at risk of infection and adverse medication reactions.