Crossroads Nursing & Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF679May 1, 2026

  Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three of seven residents (Resident # 1, Resident #2, and Resident #3) reviewed for activities.The facility failed to provide Resident #1, Resident #2 and Resident #3 in room activities three times per week, as care planned, during the months of March 2026 and April 2026.This failure could… […]

• No harm, potential for more than minimal, patternF679Dec 4, 2025

  Based on observation, interview, and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three of five residents ( Resident # 5, Resident # 45 and Resident #46) reviewed for activities.The facility failed to provide Resident #5, Resident #45, and Resident #46 in room activities three to five times per week during the months of October 2025 and November 2025. […]

• No harm, potential for more than minimal, patternF759Dec 4, 2025

  Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 12.9% based on 4 out of 31 opportunities, which involved 1 of 4 residents (Resident #13) and 1 of 2 MAs (MA D) observed during medication administration reviewed for medication error. 1. The facility failed to ensure MA D failed to administer Resident #13's physician ordered medications acidophilus lactobacillus and artificial tears. 2. The facility failed to ensure MA D failed to administer Resident #13's B12 vitamin as ordered by the physician. 3. The facility failed to ensure MA D did not administer Resident #13 a multivitamin tablet without a physician order. […]

• No harm, potential for more than minimal, patternF812Dec 4, 2025

  Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food under sanitary conditions in accordance with professional standards for food service safety for one of one kitchen.The facility failed to ensure Dietary Aide A and Dietary [NAME] B used proper hand hygiene during food preparation on 12/03/2025. This failure could place residents who ate food from the kitchen at risk for foodborne illness. Findings include: Observation on 12/03/2025 at 10:35 AM, Dietary Aide A was not wearing gloves when she opened the kitchen door leading from kitchen to the dining room. She touched the side of her pants with her ring, middle and fore finger on her right hand as she walked toward the back of the kitchen near the dishwashing room. […]

• No harm, potential for more than minimal, patternF880Dec 4, 2025

  Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents reviewed for infection control practices. A) The facility failed to ensure the ADON used aseptic technique during wound care for Resident #16By not cleaning the wound care supplies prior to treatment, not setting up the clean field per facility policy, not performing hand hygiene or glove changes at all appropriate opportunities not performing hand hygiene or glove changes between wounds, and not re-cleaning the wounds after they were contaminated during the treatment. […]