The Crescent

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 6 residents (Resident #1) reviewed for enteral feedings. 1. LVN A failed to ensure Resident #1 was wearing their abdominal binder (a special belt that is used to secure the feeding tube against the body, preventing the tube from dangling, snagging on clothing, or being accidently pulled out) on 07/30/26. 2. LVN A failed to stop Resident #1's enteral feeding (tube feeding that deliver liquid nutrition directly into the stomach or small intestines) at 7AM on 07/30/26. [...]

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 6 residents (Resident #1) reviewed for infection control. LVN A failed to practice Enhanced Barrier Precautions when administering direct care for Resident #1 on 07/30/26. This failure could place residents at risk for acquiring and spreading infections.

Inspectors wroteBased on interview and record review, the facility failed to permit residents to return to the facility after they were placed on therapeutic leave and failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals for 1 of 8 residents (Resident #11) reviewed for discharge process. The facility failed to ensure Resident #11 was allowed to return to the facility on 7/1/26 after she went out on pass on 6/30/26 resulting in the resident leaving the facility with nowhere to go. The facility failed to develop an effective discharge plan for Resident #11. This failure could place residents at risk of emotional distress, fearfulness and disorientation to discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinent care and catheter care, in that:While providing incontinent care to Resident #1 on 07/01/2026, CNA A did not spread the resident's labia. This failure could place residents at-risk for infection and skin breakdown due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were free of any significant medication errors for 1 of 11 residents (CR #2) reviewed for pharmacy services. -The facility failed to ensure CR #2 received his Hydroxyurea medication (prescription medication used to treat certain cancers) upon admission to the facility and missed 3 doses on 4/24/26, 4/26/26 and 4/28/26. This failure could place residents at risk of not receiving necessary medications and decline in health.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 1 resident (Resident #1) reviewed for dietary intake.-The facility incorrectly documented the meal percentage intake for Resident #1. This failure could place all residents at risk for unwanted weight loss and hospitalization.

Inspectors wroteBased on record review and interview the facility failed to ensure resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practices, to promote healing, prevent infection and prevent new ulcers from developing for 1 (CR #1) of 5 residents reviewed for pressure ulcers. -LVN A failed to transcribe CR #1's new wound treatment order given on 01/29/26 until 02/03/26. This failure could place residents at risk for delay wound healing.

Inspectors wroteBased on interview and record review, the facility failed to 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 resident (CR #1) of four residents reviewed for infection control. The facility failed to implement enhanced barrier precautions when LVN A entered CR #1's room and administered IV medications without donning appropriate Personal Protective Equipment (PPE). The facility failed to implement infection control prevention when LVN A did not wash or sanitize his hands after entering CR#1's room. The facility failed to implement infection control prevention when LVN A did not sanitize the resident's overbed table. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 8 residents (Resident #1) reviewed for Foley catheter care The facility failed to ensure Resident #1's Foley catheter had a leg strap to prevent being pulled or tugged on. This failure could place residents at risk for unwanted pain, discomfort, and risk of dislodgement or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the transmission of communicable diseases and infections for 1 of 8 Residents (Resident # 1) reviewed for infection control. 1. The ADON and CNA B failed to wear full PPE (disposable gown) when providing Foley catheter care for Resident #1. 2. RN A failed to wear full PPE (disposable gown) when performing Resident #1's wound dressing changes to the sacrum (large bone triangular positioned at the very base of the spine) and RL ischium (the bone that supports the upper body's weight and balance that is located near the pelvis [bone at the base of the spine]). [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 (Residents #1) reviewed for accidents hazards and supervision. The facility failed to ensure CNA A provided Resident #1 adequate supervision after she provided her with hot water for soup on 04/02/25, in which Resident #1 suffered 2nd/3rd degree burns on her right leg. The facility failed to have appropriate interventions in place to ensure hot water was tested for safe temperatures before being served to residents. These failures resulted in an Immediate Jeopardy (IJ) situation on 10/22/2025. The IJ template was provided to the facility on [DATE] at 6:53PM. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for one of five residents (Resident #1) reviewed for abuse and neglect . [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement the abuse protocol that prohibit and prevent abuse, neglect, and exploitation of residents 1 (CR#1) of 9 residents reviewed for abuse. The facility failed to prevent abuse, report the abuse allegation immediately to the Abuse Coordinator, and failed to protect the residents as the alleged perpetrator was allowed to continue to work. CR#1 reported he was physically abused on his arm by CNA A on 6/21/2025 around 2:30pm, which was the time CNA A started her afternoon shift. An Immediate Jeopardy (IJ) situation was identified on 06/26/2025. While the IJ was removed on 6/27/2025., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to report an alleged violation involving abuse or resulting in serious bodily injury immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures; that 1(CR#1) of 9 residents had been abused by CNA A, which resulted in injury. The facility staff failed to immediately report abuse to the Abuse Coordinator, the State Survey Agency and Law Enforcement. An Immediate Jeopardy (IJ) situation was identified on 06/26/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence that all alleged violations of abuse were thoroughly investigated, to prevent further potential abuse or mistreatment while the investigation was in progress, and report the result of all investigations to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident for 1 (CR#1) of 9 residents reviewed for abuse. The facility failed to ensure resident(s) was/were free from physical/mental abuse and neglect when CR#1 reported he was abused by CNA A and received an injury. The facility staff failed to immediately report the incident to the Abuse Coordinator (ED), suspend staff, and being an investigation of the incident promptly. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 9 residents (CR#1) reviewed for abuse and neglect. 1. The facility failed to prevent CNA A from having access to CR#1 and other residents after an allegation of abuse was made. 2. The facility failed to ensure CR#1 was free from physical/mental abuse and neglect when CR#1 reported he was abused and threatened by CNA A. CR#1 sustained an injury on the left arm on 6/21/25. An Immediate Jeopardy (IJ) situation was identified on 06/25/2025. While the IJ was removed on 6/26/2025., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate administration of all drugs to meet the needs of each resident for 2 of 6 residents (Resident #1 and CR#2) reviewed for pharmacy services. The facility failed to ensure that Resident #1 received his prescribed blood pressure medication metoprolol, as ordered by his physician. The facility failed to ensure that CR#4 received his prescribed blood pressure medications metoprolol and Midodrine as ordered by his physician. This failure could place residents at risk of medication overdose, medication under-dose, and ineffective therapeutic outcomes by not documenting when medications were held.

Inspectors wroteBased on record review and interviews, the facility failed to provide and document sufficient preparation and orientation of residents to ensure safe and orderly transfer or discharge from the facility for 1 of 1 resident (Resident #3) reviewed for transfer and discharge rights. -The facility failed to notify the representative (Office of the State Long-Term Care Ombudsman) of the transfer or discharge with the reasons for the move in writing in a language and manner they understand. This failure placed residents at risk of not receiving an advocate who can inform them of their options, rights, and the added protection from being inappropriately transferred or discharged .

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate administration of all drugs to meet the needs of each resident for 2 of 11 residents (CR#3, Resident #4) reviewed for pharmacy services. The facility failed to ensure that CR#3 and Resident #4 received their prescribed medications, as ordered by their physician. This failure could place residents at risk of medication overdose, medication under-dose, and ineffective therapeutic outcomes by not documenting when medications were given or not given.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide the necessary care and services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 resident (Resident #1) of 11 residents reviewed for ADLs. The facility failed to ensure Resident #1's fingernails were cleaned and trimmed on 2/21/2025. These failures could place residents at risk for loss of dignity due to not receiving care and assistance with daily living activities.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided a PASRR level 2 evaluation for 5 (Resident #4, Resident #5, Resident #43, Resident #66, and Resident #82) of 5 residents reviewed for resident assessments. The facility did not correctly identify Resident #4, Resident #5, Resident #43, Resident #66, and Resident #82 as having mental illness in their PASRR Level 1 Screening. This failure could place residents with documented mental illness diagnoses at risk of not receiving needed care and services in the appropriate setting.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 2 (Resident #240 and #73) of 8 residents reviewed for respiratory care. The facility failed to ensure Resident #240 and #73's had physician's orders for O2 administration prior to providing oxygen. The facility failed to label and date oxygen tubing and the humidifier for rResident #73. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. Findings Include: [...]

Inspectors wroteBased on record review, and interview 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 that meets professional standards of quality of care for 1 of 8 (Resident #82) residents reviewed for base line care plans. The facility failed to develop a baseline care plan that addressed the PASRR diagnosis for Resident #82. This failure could place a new resident at risk of not receiving necessary care and services or having important care needs identified. Findings Include: [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement person-centered care plans for each resident, consistent with resident rights that included measurable objective and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 12 residents (Resident #73) reviewed for comprehensive care plans. The facility failed to ensure Resident #73's comprehensive care plan included the care for her rectal tube. This failure could place the resident at risk for appropriate interventions to meet their care needs. Findings Include: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 of 5 residents (Resident #49) reviewed for incontinent care and for indwelling urinary catheters. The facility failed to ensure Resident #49's indwelling catheter (a tube into the bladder to drain urine) stabilizer (strap or secure device attached to the resident's thigh to prevent the tube from moving) was in place. This failure could place residents At risk for not receiving the appropriate catheter care.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 garbage dumpsters (dumpsters #1 and #2) reviewed for disposal of garbage. The facility failed to ensure 2 of 2 dumpster lids were secured. This failure could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 of 9 residents (Resident #1) reviewed for incontinent care and for indwelling urinary catheters. The facility failed to ensure Resident #1's indwelling catheter (a tube into the bladder to drain urine) stabilizer (strap or secure device attached to the resident's thigh to prevent the tube from moving) was in place. This failure could place residents with urinary catheters at risk for accidental dislodgement of the catheter and trauma to the bladder and urethra.

Inspectors wroteBased on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 5 of 5 residents (CR #1, CR #2, CR #3, CR #4, CR #5) reviewed for transfer and discharge rights. 1. The facility failed to arrange a safe and orderly discharge through care planning and involving CR #1, CR #2, CR #3, CR #4 and CR #5. 2. The facility failed to secure a home health agency prior to CR #1's discharge from the facility on 8/9/24. This failure placed residents at risk of not receiving care and services to meet their needs upon discharge.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered baseline care plan within 48 hours of admission that includes the minimum healthcare information necessary to properly care for a resident for 1 of 1 resident (CR#1) reviewed for care plans in that: CR#1 did not have a baseline care plan that addressed her initial goals based on admission orders, physician orders, therapy services, social services or PASRR . This failure could place newly admitted residents at risk of not receiving services to meet their needs.

Inspectors wroteBased on record review and interview the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 9 residents (CR#1) reviewed for quality of care. -The facility failed to obtain wound care orders for CR#1's left toes and left foot upon admission on [DATE]-[DATE]. This failure could place residents at risk for delay in needed treatment and care, resulting in further injury, hospitalization, and/or death.

Inspectors wroteBased on record review and interview the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 9 residents (CR#1) reviewed for wound care. -The facility failed to obtain wound care orders for CR#1's sacral wound upon admission on [DATE]-[DATE]. This failure could place residents at risk of not receiving adequate care in a timely manner, deterioration of skin, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (CR#1) out of 9 residents reviewed for reporting. [...]

Inspectors wroteBased on interviews and records reviews, 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 of the resident that meet professional standards of quality of care for 1 (CR#1) of 9 residents reviewed for base-line care plans. -The facility failed to ensure (CR#1) had a baseline care plan developed within 48-hours after admission with goals and interventions to address wound care. The failure could place newly admitted residents at risks of not receiving the care and continuity of services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 9 residents (Resident #2) reviewed for comprehensive care plans. The facility failed to provide Resident #2 with comprehensive person-centered care plan to address his diagnosis of epilepsy, orders for oxygen therapy, and orders for a feeding tube. This failure could place residents at risk of not having personalized plans developed to address their specific care needs.

Inspectors wroteBased on interviews, and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 10 residents (CR#1) reviewed for changes of condition . -The facility did not notify CR#1's physician of his changes in condition on [DATE], after which EMS was called, and transported the resident to the hospital where he passed away two days later, on [DATE]. On [DATE] an Immediate Jeopardy (IJ) situation was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility continuing to monitor the implementation and the effectiveness of their Plan or Removal. These failures could place residents at risk of not receiving needed care and services to meet their physical, mental, and psychosocial needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident's right to be free from neglect for 1 of 10 residents (CR#1) reviewed for neglect. The facility did not appropriately assess, document assessments, notify the physician, follow physician orders, provide ongoing monitoring, or provide emergency medical treatment in a timely manner, after CR#1 experienced changes in condition on [DATE], after which EMS was called, and transported the resident to the hospital where he passed away two days later, on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 1 residents (Resident #2) reviewed for transfer and discharge rights. 1. The facility failed to arrange a safe and orderly discharge through care planning and involving Resident #2. 2. The facility failed to secure a home health agency prior to Resident #2's discharge from the facility on 07/15/24. This failure placed residents at risk of not receiving care and services to meet their needs upon discharge.

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 infection for 1 of 4 residents (Resident #2) reviewed for infection. -The facility failed to ensure CNA JJ and CNA RR performed hand hygiene during incontinent care on Resident #2. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress.

Inspectors wroteBased on interview and record review, the facility failed to include the location to which the resident is transferred or discharged ; the correct name, address (mailing and email) and telephone number of the Office of the State Long Term Care Ombudsman for two (CR #1 and Resident #2) of three residents reviewed for discharge. -The facility gave CR #1 and Resident #2 a 30-day written notices which failed to include the location to which the resident would be transferred and a correct phone number to contact the office of the state long term care ombudsman. This failure could affect residents by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 3 rooms observed for pest control, in that. The facility failed to ensure the environment was free of roach infestation. This deficiency could expose residents living in the facility to infection (through the infestation), illness, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Resident #8 with emergency dental services for 1 of 3 (Resident #8) residents reviewed for dental services. Resident #8, who first complained of tooth aches starting 12/28/2023 was not seen by a licensed dentist or referred for emergency dental services until after 01/25/2024. This failure could place residents at risk of not having their immediate dental care needs met.

Inspectors wroteBased on interviews and record reviews the facility failed to consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) of a significant change in the resident's physical, mental, or psychosocial status and transfer for 1 resident (CR#1) of 5 residents reviewed for changes of condition. The facility failed to notify CR#1's family member that CR#1 was being transferred to a psychiatric hospital for evaluation. Record review of CR#1's face sheet dated 08/04/23 revealed that he was a [AGE] year-old male that was originally admitted to the facility on [DATE]. He had the diagnoses of bipolar disorder , iron deficiency, laceration of unspecified part of small intestine, insomnia, hypertension, and muscle spasms. Face sheet revealed CR#1 had a designated responsible party. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of 5 medication carts (Nurse 700 hall medication cart) reviewed for medication storage. The facility failed to ensure the nurse 700 hall medication cart was secured when unattended. This failure could place residents at risk for loss of medications, resident's safety, and drug diversion.