Crescent Cities Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Crescent Cities Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 14, 2024

  Based on interview, record review, and facility policy review, the facility failed to ensure one of one resident (Resident (R) 44) reviewed for safe transfers from a total sample of 39 was safe during a transfer that required a mechanical lift. This failure caused R44 to have a right femur fracture. Upon identification of the fracture, the facility failed to report the fracture, failed to conduct a root cause analysis of the fracture, and failed to ensure staff were provided education on proper mechanical lift transfers. R44 reported to Geriatric Nursing Assistant (GNA) 1 on an unknown date that she was afraid of the Hoyer lift because of a previous incident. GNA1 reported this information to the nurse on duty (Licensed Practical Nurse (LPN) 1). […]

• Immediate jeopardy, isolatedF689Nov 29, 2021

  Based on observations, a review of the medical record and other pertinent documentation, and interviews with facility staff it was determined the facility failed to have a system in place that: 1.) Ensured cognitively impaired residents with exit seeking behaviors did not leave the building unauthorized, 2.) Ensured facility exit doors were secured and locked appropriately, 3.) Ensured that residents with wander guards in place were functioning correctly and alarmed when a resident was near an exit door. Failure of the facility to have a system in place that keeps cognitively impaired residents with exit seeking behaviors from leaving the building unsupervised places residents with a history of exit seeking behaviors at risk. […]

• No harm, potential for more than minimal, widespreadF880Jan 13, 2021

  Based on CMS guidance, facility documentation and policies & procedures, observations, and staff interviews it was determined that the facility failed to ensure an effective infection prevention and control program by failing to follow infection prevention and control guidelines by not keeping the doors closed of isolated residents on airborne, droplet, and contact precautions on the facilities COVID-19 observation unit (Riverdale Unit), failing to ensure soiled linen and trash bags were placed in the appropriate location (Terrapin Unit) and failed to maintain an effective infection control surveillance. Facility Census 150. […]

• No harm, potential for more than minimal, patternF803Mar 2, 2026

  Based on observation, record review, and interview, it was determined that the facility failed to ensure that residents were served meals according to predetermined menus. This was evident for 4 (Residents #92, #34, #121 and #48) of 6 random meal trays sampled during the lunch tray line observation.The findings include: Pureed diet is a texture- modified diet consisting of smooth, moist, pudding-like food requiring no chewing. Designed for residents with swallowing difficulties. Thickened liquids are beverages or fluids with added agents (powder/gel) to increase viscosity, designed for residents with swallowing difficulties. On 2/24/2026 at 10:11 AM, Resident #1 reported frequently receiving items that do not match their meal ticket. […]

• No harm, potential for more than minimal, patternF812Mar 2, 2026

  Based on observation, interview and record review, it was determined that the facility failed to maintain the ice machines in a clean and sanitary manner. This was evident in 2 of 5 ice machines inspected during the recertification survey. This practice has the potential to affect all residents who consume food prepared by the facility. The findings include: On 2/24/2026 at 9:15 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM), the surveyor observed the ice machine was last cleaned on 9/25/25 as indicated on the Cleaning schedule document that was found hanging on the side of the ice machine. […]