Crescent City Care Center

In the surveyor’s words

From the most serious findings on record at Crescent City Care Center, in the surveyor’s own words.

• Actual harm, patternF689Jun 21, 2024

  Based on observation, interview and record review, the facility failed to ensure 2 of 24 sampled residents (Resident 28 and Resident 15) and one discharged resident (Resident 233) who were at risk for falls and had a history of falls, were provided with supervision by direct care staff, and had effective revisions and implementation of their nursing care plans to prevent further falls to keep them safe. Facility policies on safety and management of falls were not followed. As a result, Resident 28, Resident 15 & Resident 233 suffered falls with major injuries at the facility. This may have contributed to Resident 233's death, and Resident 28's dramatic decline, as she is now expected to pass away within 6 months. […]

• Actual harm, patternF692Jun 21, 2024

  Based on observation, interview and record review, the facility failed to provide the necessary care and services related to significant and/or severe weight loss or gain for five out of 23 sampled residents (Resident 12, 20, 25, 29 and 227) to ensure the residents maintained an acceptable nutritional status because: 1. The RD (Registered Dietician) was making quarterly visits (once every three months), which led to minimal in person resident assessments, 2. The RD failed to fully tailor the resident's nutritional interventions to the resident's needs and monitor the continued relevance of those interventions such as residents' functional factors and lack of adequate assistance or supervision during meals, 3. […]

• Actual harm, isolatedF835Jun 21, 2024

  Based on observation, interview, and record review, the facility's Administrator failed to ensure effective oversight and necessary resources to ensure the residents' quality of care, safety, dignity, and dietary services, which include maintenance of the resident's nutrition and hydration were met to attain or maintain the highest practicable physical, mental, and psychosocial well-being for all 81 residents when: 1. The Quality Assurance and Performance Improvement Committee, whose members included the Administrator did not make sure an action plan was implemented to reduce the number of falls in the facility and promote a resident safety plan by monitoring trends and implementing changes through careful analysis of the falls, which led to 134 falls from January 2024 through May 2024. […]

• No harm, potential for more than minimal, widespreadF695Mar 27, 2026

  Based on observation, interview, and record review, the facility failed to ensure that residents requiring oxygen were provided humidifiers (bottled water that attaches to an oxygen concentrator and moistens the oxygen, preventing dry nose and throat), clean concentrators (a medical device that provides supplemental oxygen to people with breathing-related conditions by pulling in ambient air, filtering out nitrogen, and delivering purified oxygen) and orders for therapy for 13 of 15 residents (Residents: #18, #20, #23, #22, #25, #31, #40, #41, #98, #48, #55, #76, #81) observed receiving oxygen therapy when thirteen residents did not have humidifiers in use as required for their oxygen delivery systems, seven residents had visibly soiled or dirty oxygen concentrator filters, and eleven… […]

• No harm, potential for more than minimal, widespreadF725Mar 27, 2026

  Based on observation, interview and record review, staffing was not sufficient to meet the needs of thirteen Sampled Residents (Resident #6, Resident #29, Resident #55, Resident #9, Resident # 35, Resident #86, Resident #53, Resident #3, Resident # 34, Resident 54, Resident 81, Resident #5, and Resident #67 when:There was no staff assistance with dining for Sampled Residents #9, #86 and #35 and resulted in no lunch eaten by all three residents; and Sampled Resident #86 was not turned every two hours. Staff did not provide activities of preference for Sampled Resident #34, did not provide nail care for Residents #6, #29. […]