La Crescent Health Services

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Apr 14, 2026

  Based on observation, interview, and document review, the facility failed to prevent complications of enteral feeding and failed to provide appropriate treatment and services for 1 of 1 resident (R5) reviewed who required tube feedings and medication administration through a gastrostomy tube (g-tube). This failure created the likelihood of serious harm for R5, including worsening symptoms of nausea and vomiting, and additional hospital visits. The immediate jeopardy (IJ) began on 4/8/26 when the facility failed to follow professional standards of medication administration through a g-tube, pharmacy directions for medication administration, identify the symptoms and side effects of incorrectly using the g-tube. […]

• No harm, potential for more than minimal, widespreadF841Apr 14, 2026

  Based on interview and document review, the facility failed to ensure 1 of 1 medical director had appropriate oversight of policies and procedures and ensured appropriate medical care was being provided for 1 of 1 (R5) resident who experienced complications from tube feedings and medication administration through a gastrostomy tube (g-tube).Refer to 684 Findings include: R5's quarterly Minimum Data set (MDS) dated [DATE], indicated R5 had clear speech, no hearing disabilities, and used corrective lenses. R5 had moderate cognitive impairment with no rejection of care. R5 had no impairments of her upper extremities and used a walker. […]

• No harm, potential for more than minimal, widespreadF812Feb 6, 2025

  Based on observation, interview, and document review, the facility failed to ensure refrigerated food items were disposed of after expiration date and were properly stored, labeled and dated. This had the potential to affect 28 of 28 residents, staff and visitors who may eat from the facility kitchen. Findings include: During an initial tour of the kitchen on [DATE] at approximately 1:51 p.m., while verifying temperatures of the refrigerators, it was identified a box of oranges dated [DATE] with what looked like some white fuzz on one of the oranges and brown liquid coming from a bag of grapes. […]

• No harm, potential for more than minimal, widespreadF812Aug 25, 2022

  Based on observation, interview, and document review, the facility failed to maintain clean and sanitary equipment in 1 of 1 kitchen to prevent the potential spread of food-borne illness. This deficient practice had the potential to affect all 25 residents residing in the facility. In addition the facility failed to ensure frozen food items were properly labeled and dated when the original packaging was opened. Findings included: On 8/22/22, at 1:27 p.m. an initial tour of the kitchen was completed with dietary manager (DM) and kitchen manager (KM)-A identified the kitchen under the sink cabinet was soiled with black mold or dirt-like spots and food-like debris was noted to be spattered inside the cabinet. […]

• No harm, potential for more than minimal, patternF804Apr 14, 2026

  Based on observation, interview and document review, the facility failed to ensure food was served in a timely manner to preserve desired temperatures of food for 4 of 4 residents (R1, R10, R15, R30) reviewed who expressed concerns for food temperatures and palatability. This had the potential to affect all residents who consumed food from the facility kitchen. Findings include: On 4/8/26 at 1:34 p.m., an informal resident council meeting was held with R10, R15 and R30. The residents were asked, as part of the meeting, about bedtime snacks which prompted a conversation regarding food. R30 stated that she eats in the dining room for her meals and her food was frequently served cold. R30 stated this had been an issue for a long time and had talked to staff about this. […]