Crescent Health Care

In the surveyor’s words

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

• Immediate jeopardy, patternF880Feb 16, 2022

  Based on observation, interview, and record review, the facility failed to operationalize all components of an effective infection prevention and control program (ICP) when there were multiple breaches in the ICP related to the following failures: A) Implementation of correct transmission-based precautions (TBP, safeguards to prevent spread of diseases) in six out of six (18, 20, 21, 22, 23, and 24) resident rooms that were confirmed positive for the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) virus; B)… […]

• Actual harm, isolatedF689Mar 11, 2026

  Based on observation, interview and record review the facility failed to identify and prevent an avoidable accident hazard in the resident's environment for 1 of 3 residents (Resident 1) that used both bed bolsters (a soft barrier along the edge of the bed that minimizes the risk of rolling off the bed) and required mechanical lift transfers. Resident 1 experienced harm when they slid out of the lift sling during two-staff assist transfer when the resident in the sling did not clear the top edge of the bolster there by lifting the lower left sling loop up off the lift hook due to no longer being taut and the loop disconnected from the lift. The fall resulted in pain, a forehead wound, and transfer to the hospital where they were diagnosed with an ankle fracture. […]

• Actual harm, isolatedF689Dec 5, 2025

  Based on interview and record review, the facility failed to provide adequate supervision, immediately assess a resident after a fall, implement and evaluate care-plan interventions for efficacy, and ensure care-planned interventions were consistently followed to prevent an avoidable fall for 1 of 5 residents (Resident 54) reviewed for hospitalizations. Resident 54 who had moderately impaired cognition with a known history of falls prior to admission and was assessed at high risk for falls, experienced harm when they had an unwitnessed fall, were found face down on the floor with multiple lacerations, required transfer to the hospital for pain, and were diagnosed with multiple complex fractures (left humerus, hip, and left tibia) which required surgical intervention.Findings included… […]

• Actual harm, isolatedF686Dec 9, 2024

  Based on observation, interview, and record review the facility failed to consistently assess skin and/or wounds or implement interventions to ensure the prevention and the worsening of facility-acquired pressure injuries (PI) for 1 of 4 residents (Resident 30) reviewed for PIs. Resident 30 experienced harm when they developed three avoidable PIs (right heel, left heel, and left calf) that were not present upon admission, and a decreased quality of life due to the pain. Findings included . Review of the National PI Advisory Panel's (NPIAP, the leading expert in PIs/wounds) guidelines and definitions, dated September 2016, defined PI stages as follows: Stage 1 PI has intact skin with a localized area of non-blanchable erythema (redness). […]

• Actual harm, isolatedF688Dec 9, 2024

  Based on observation, interview and record review, the facility failed to ensure restorative therapy services including the consistent use of braces/splints were implemented timely to prevent avoidable reduction of range of motion (ROM) and mobility for 2 of 5 sampled residents (Residents 27 and 20) reviewed for restorative therapy. Resident 27 experienced harm when they developed right and left-hand contractures (a condition of shortening and hardening of muscles, tendons, or other tissue that leads to muscle stiffening and loss of range of motion of the effected body part). This failed practice placed other residents at risk for contractures, decreased mobility, and pain. Findings included . […]