Crescent City Care Center's Director of Nursing told federal inspectors in June that the falls kept mounting: 28 in January, 34 in February, 35 in March, 12 in April and 25 in May. Three of those falls resulted in major injuries.
"Although the number of falls were being tracked, interventions for fall prevention measures were not being tracked," the Director of Nursing admitted during the inspection. She said department heads had never met specifically to discuss falls or decide what to do about them.
The facility's fall prevention project in its computer system had several areas that were blank or empty when shown to inspectors.
The Director of Nursing said she couldn't do her job. "The Administrator will not let her do her job duties as a DON," according to the inspection report. She told inspectors that department heads were supposed to bring her reports about resident concerns to enter into the quality improvement system, but they weren't bringing the reports.
She bought a screen and projector for quality meetings, but said they were inefficient because of insufficient participation by department heads.
The facility's Medical Director, identified as Physician 1, attended only five of 12 quality meetings over 15 months. He missed the November 30, 2023 quarterly meeting entirely. The last meeting he attended before that was July 20, 2023 — a six-month gap.
When inspectors pressed Physician 1 about what the quality committee had implemented for fall prevention, he deflected. "Physician 1 felt surveyors were not looking at the big picture when discussing weight loss/gain and falls," the report states. "Physician 1 stated, You are not looking at the Forest through the Trees."
In a follow-up phone interview, Physician 1 acknowledged falls were "a big issue that should be trended to see why the resident was falling, what time of day, interventions updated, etc." But he said questions about monitoring and implementing safeguards "would be something to address with the Administrator."
When an inspector noted the facility had over 50 falls in a two-month period without analyzing trends, Physician 1 responded: "I agree."
The facility's quality improvement plan for 2024-2025 included goals to reduce falls with major injury by 1.9 percent and decrease total falls by 50 percent. But the Director of Nursing said the Fall Committee "never got done."
Weight loss tracking fared no better. The Director of Nursing said the Assistant Director of Nursing was responsible for tracking weight issues but hadn't provided any information. When she showed inspectors the weight loss project on her computer, it was blank with no data entered.
The Administrator knew about weight loss issues among residents but no decisions had been made about what to measure, the Director of Nursing told inspectors. Staffing issues weren't being tracked either.
The facility's infection control problems were equally systematic. During lunch observations on June 10, inspectors watched five residents get served their meals without any hand washing or wiping beforehand.
Resident 13 was served lunch in his room with no offer to clean his hands. When asked, he confirmed staff hadn't offered to wash or wipe his hands.
In the social dining room, no residents received hand sanitizer or washing services before eating bread they would touch with bare hands. Resident 61 and Resident 21 confirmed they weren't offered hand sanitation before lunch.
The Director of Staff Development was helping serve lunch that day but told inspectors she didn't sanitize residents' hands before meals.
Resident 14 revealed the facility's pattern: staff began providing hand sanitizer after June 10, but stopped again during the weekend when inspectors weren't present. "Hand sanitizer was offered to the residents prior to their meals only when the Surveyors were present," according to her account.
In the Total Assisted Dining room, one staff member used the same gloves while feeding three residents simultaneously. The worker fed Resident 4 on his left, Resident 2 on his right, then helped Resident 227 cut meat and opened her Cheetos — all with the same gloves.
Another staff member finished feeding Resident 52, then started feeding Resident 55 without sanitizing hands between residents.
During a June 12 observation, Resident 29, who is blind and Spanish-speaking, had been playing with a balloon touched by other residents and staff. No hand hygiene was offered before her lunch, and no staff member spoke Spanish to help her locate food on her plate. She ate pasta with her uncleaned fingers.
"None of the residents in the TAD Room were offered hand hygiene before lunch," one staff member acknowledged when asked.
Another worker seemed surprised by the expectation: "You mean to offer each resident a washcloth before each meal?" When confirmed, the worker said: "That did not happen, offering each resident a washcloth to wash their face and hands before each meal."
The facility's Infection Preventionist confirmed the violations were serious. A nursing assistant "should not be feeding three residents in the TAD Room with the same gloves," she told inspectors. "The CNA should use a new pair of gloves to feed each resident and hand sanitize after removing the old pair of gloves and before applying the new pair of gloves to prevent cross contamination."
Staff blamed missing equipment. One worker said hand sanitizing was missed because the dispenser was mounted on the hallway wall outside the dining room, not inside where residents ate.
The kitchen had its own maintenance failures. Inspectors found standing water in floor drains and missing tiles containing food debris in the dry storage area. The maintenance staff member was unaware of the drainage problem and said he relied on dietary staff to report issues.
But the facility's cleaning checklists didn't include floor drains, and the Registered Dietitian's food safety checklist from August failed to identify the missing tiles or drainage problems.
Multiple staff members told inspectors they weren't trained to offer washcloths to residents before meals. The facility's hand hygiene policy required staff, visitors and volunteers to wash hands before eating, but didn't specify that staff should help residents do the same.
The Director of Nursing implemented a disciplinary plan for frequent staff call-offs: verbal warning, written warning, suspension, then termination. She said the owner liked the plan and asked for immediate implementation.
Quality meetings that did occur lasted just 15 to 30 minutes. The facility's policy called for using Plan-Do-Study-Act cycles to identify problems and implement solutions, but the tracking systems remained largely empty.
The 134 falls represented an average of nearly one fall per day at the facility during the five-month period inspectors reviewed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crescent City Care Center from 2024-06-21 including all violations, facility responses, and corrective action plans.