Crescent Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Crescent Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF726Sep 12, 2024

  Based on observations, record review and staff interviews, the facility failed to ensure licensed nurses were knowledgeable, and competent in the disinfection of multi-residents shared glucometers in accordance with manufacturer's specifications. On 9/10/24 through 9/11/24, four licensed nurses on two different shifts and all three units of the facility were observed using multi-residents shared glucometers. The licensed nurses failed to disinfect the glucometers between each resident use. This failure placed 17 (Residents #82, #14, #11, #34, #4, #46, #21, #12, #49, #10, #59, #339, #27, #338, #41, #33, #54) of 17 residents requiring blood glucose testing at risk of exposure to blood-borne disease causing microorganisms which could result in serious illness or death of the residents. […]

• Immediate jeopardy, patternF880Sep 12, 2024

  Based on observation, record review and staff interviews the facility failed to maintain an on-going infection prevention and control program by failing to ensure multi-residents shared glucometers (blood glucose meters) were properly disinfected between each resident use to prevent cross contamination and spread of infectious agents to 17 (Residents #82, #14, #11, #34, #4, #46, #21, #12, #49, #10, #59, #339, #27, #338, #41, #33, #54) of 17 residents requiring blood glucose testing. On 9/10/24 through 9/11/24 a total of four licensed nurses on different shifts and units were observed using multi-residents shared glucometers. […]

• No harm, potential for more than minimal, widespreadF908Apr 29, 2021

  Based on interview and maintenance review, the facility failed to have documentation of maintenance of resident care equipment to ensure safe operating condition. The finding included: On 4/28/21 at 3:00 p.m., a tour of the facility's laundry with the Housekeeper Supervisor was conducted. The laundry room had 2 washing machines and 3 dryers. The Housekeeping Supervisor stated the temperature of the machines were 160 degrees. The washing machines had three filters and had the following chemicals: sanitizer chlorine, detergent, softener, which were calibrated to run during the different washing cycles. On 4/28/21 at 3:15 p.m., in an interview, Housekeeper Supervisor stated, The service was once a month, not sure of the last service or the changing of the filters. […]

• No harm, potential for more than minimal, patternF584Sep 12, 2024

  Based on observation and interview the Facility failed to ensure a clean and sanitary environment by failing to ensure the carpets in the halls of the facility and several rooms in the facility (rooms 616, and 610) were clean and sanitized, failing to ensure the walls were free form streaks, gouges and pealing wallpaper (rooms 616, 614, 610, and 609) the privacy curtains in room [ROOM NUMBER] and 610 were free from stains, The roof was in good repair and the ceiling in room [ROOM NUMBER] was free from signs of leaking, also, the hand rails were free from worn areas, and the hand rails were free from dirt and debris throughout the facility. The findings included: On 9/11/24 at 10:30 a.m., stains were observed on the carpets throughout the 100, 200, and 300 hallways. […]

• No harm, potential for more than minimal, patternF686Sep 12, 2024

  Based on observation, record review and staff interview, the facility failed to implement physician's ordered interventions to prevent the development of avoidable pressure ulcers for 1 (Resident #34) of 5 sampled residents identified at risk for development of pressure ulcers. The findings included: Review of the clinical record for Resident #34 revealed an admitted [DATE]. Diagnoses included left hemiplegia (paralysis of the left side of the body). The Admission Minimum Data Set (MDS) assessment with a target date of 8/15/24 noted Resident #34 was dependent on staff for mobility, including rolling left and right. At the time of the assessment, Resident #34 did not have a pressure ulcer but was at risk of developing pressure ulcers. […]