The facility gave Resident #19 crushed Jardiance tablets through a gastrostomy tube daily starting April 30, according to May 2025 medication records reviewed by inspectors. The resident had been admitted from a hospital with diagnoses including congestive heart failure, protein-calorie malnutrition, and a gastrostomy tube.
Jardiance should not be crushed, according to a Google search conducted by inspectors on September 8. The resident's own physician confirmed this during an interview that same day at 2:15 PM, telling inspectors "the medication Jardiance should not be crushed and administered through a feeding tube."
The medication error came to light during a complaint investigation alleging Resident #19 "did not receive quality care during his/her stay." Inspectors reviewed the resident's closed medical record on September 8, finding the Jardiance order written on April 30, 2025, instructed staff to give the 10 mg tablet "once a day via feeding tube for diabetes."
The resident's physician had ordered nursing staff to weigh the patient three times weekly on May 2, with instructions to notify the doctor of any two-pound weight increase. Jardiance is prescribed to help control blood sugar in people with type 2 diabetes, but crushing the medication can alter its effectiveness and safety profile.
A second medication violation involved Resident #7, whose behavior monitoring requirements were ignored by nursing staff. The resident had a physician's order from January 29 directing nurses to monitor for specific behaviors including "exit seeking, increase in complaints, kicking, cussing, non-adherence to the smoking policy, and refusing care."
The order required detailed documentation. If no concerning behaviors occurred, nurses were to document "N." If any behaviors were observed, they were to document "Y," select "Other/See nurses notes," and "note findings every shift." The physician specifically ordered staff to "Document behavior, interventions and outcomes in progress notes."
On August 12, during the evening shift, a nurse documented "YES" under behaviors on Resident #7's medication record. But when inspectors reviewed the resident's nursing progress notes from that date, they found no description of what behavior the nurse had observed.
The notes contained no record of nursing interventions attempted with the resident. There was no documentation of outcomes from any interventions. The physician's explicit instructions for detailed behavior tracking had been completely ignored.
Resident #7 was also receiving Melatonin 1 milligram at bedtime for insomnia, according to physician orders reviewed by inspectors on August 19. The behavior monitoring order suggested the resident was experiencing multiple challenging behaviors that required careful tracking and intervention.
The medication violations occurred at a 180-bed nursing facility on East West Highway that provides rehabilitation and long-term care services. Both violations were classified as causing "minimal harm or potential for actual harm" to residents.
Federal inspectors completed their complaint survey on September 12, finding the facility had failed to ensure residents' drug regimens were "free from unnecessary drugs." The crushing of Jardiance represented an unnecessary alteration of the medication that could have compromised its therapeutic effect or created safety risks for the resident.
For Resident #19, the medication error continued for months without detection. The resident required careful monitoring for weight gain due to congestive heart failure, but was receiving improperly prepared diabetes medication through the feeding tube during this same period.
The behavior monitoring failure for Resident #7 meant physicians lacked crucial information about the resident's condition and response to interventions. Without proper documentation of behaviors, interventions, and outcomes, medical staff could not adjust treatment plans or identify patterns that might indicate underlying medical issues.
The inspection found these violations affected "few" residents overall, but represented systemic failures in medication management and clinical documentation. Both cases involved fundamental breakdowns in following physician orders and maintaining basic safety protocols for vulnerable residents requiring complex medical care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crescent Cities Nursing & Rehabilitation Center from 2025-09-12 including all violations, facility responses, and corrective action plans.
Additional Resources
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