Crescent Manor Care Ctrs

In the surveyor’s words

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

• Immediate jeopardy, patternF880Jun 9, 2021

  Based on observations, staff interviews and review of facility policies, the facility failed to ensure infection control measures were carried out to maintain resident safety from the spread of potential infections. This is cited at the Immediate Jeopardy severity level. Findings include: 1. Per observation on 06/09/21 at 11:00 AM, during a medication administration pass, a staff nurse checked the blood glucose of a resident prior to giving insulin using a device called a glucometer, which is used for multiple residents and utilizes a sample of resident blood to obtain a blood glucose level. S/he returned to the medication cart, removed the test strip from the glucometer and placed the device in the top drawer of the cart without cleaning the device. […]

• Actual harm, isolatedF686Oct 2, 2024

  Based on observations, interviews, and record review, the facility failed to ensure that 1 of 25 residents in the applicable sample (Resident #87) received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection. As a result, Resident #87's pressure ulcer worsened to stage four, developed an infection, the resident required hospitalized and surgical debridement of the wound, and was not stable enough to be discharged . Findings include: Per record review Resident #87 was admitted to the facility in July 2024 with a goal to discharge home. […]

• Actual harm, isolatedF600Oct 23, 2023

  Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one applicable resident (Resident #1). Findings include: Record review reveals that Resident #1 has a diagnosis of dementia with psychosis and was assessed on 8/22/23 to have a BIMS of 4 (brief interview for mental status; a cognitive assessment score indicating severe cognitive impairment). Resident #1's care plan states that s/he wanders throughout hall/facility/into others room R/T [related to] dementia and independent mobility, revised on 9/5/23, and has interventions that include, Distract [Resident #1] from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, revised on 2/15/23, and Identify… […]

• Actual harm, isolatedF689Oct 23, 2023

  Based on interview and record review, the facility failed to ensure that all known and foreseeable hazards in the resident's environment were eliminated and failed to provide sufficient supervision to each resident for 2 applicable residents (Resident #1 and #2) resulting in Resident #1 being physically abused. Findings include: Record review reveals that Resident #1 has a diagnosis of dementia with psychosis and was assessed on 8/22/23 to have a BIMS of 4 (brief interview for mental status; a cognitive assessment score indicating severe cognitive impairment). […]

• Actual harm, isolatedF692Jun 9, 2021

  Based on interview and record review, it was determined that the facility failed to maintain acceptable nutritional supports to residents at risk and who had significant weight loss for 1 of 20 residents in the survey sample (Resident #56). Findings include: Review of the electronic medical record (EMR), revealed that Resident #56 was admitted to the facility in June 2020. The resident has had a significant avoidable weight loss while in the facility. The resident has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident lost 18.5 pounds, which is 15.23% of her/his body weight within a 90 day period. On 2/11/21 her/his weight was 121.5 and on 5/13/21 her/his weight was documented as 103.0. […]