The incident at Crescent Cities Nursing & Rehabilitation Center occurred on November 20, 2024, when a family member visited Resident #25 around 2:30 PM and found the patient soaked in urine. The family member asked nursing staff for help changing the resident.
RN #21 refused. The nurse told the family that Resident #25 had received incontinence care at 1 PM and would have to wait until the evening shift arrived at 3 PM because "the GNA staff had left for the day."
Resident #25 is completely dependent on nursing staff for all care. The patient cannot speak and suffered a stroke that left the right side of the body weakened. The resident requires a feeding tube and breathes through a tracheostomy.
The patient had been taking a powerful diuretic for four days when the incident occurred. On November 16, a chest x-ray revealed mild congestive heart failure and fluid buildup in the lungs. The physician prescribed Lasix, a medication that forces the body to eliminate excess fluid through urination, for eight consecutive days.
Federal inspectors investigated after receiving a complaint in January 2025 about delayed incontinence care for the resident.
RN #21 acknowledged the incident during an interview with inspectors on September 11, 2025. The nurse confirmed that the family member had requested assistance with incontinence care for Resident #25 that day in November.
The nurse told inspectors that Resident #25's care plan required turning and repositioning at least every two hours. RN #21 also stated that nursing staff "can provide care more often if necessary."
The resident finally received incontinence care after 3 PM when the evening shift nursing staff arrived.
Activities of daily living include fundamental skills like eating, toileting, bathing, and mobility. Federal regulations require nursing homes to provide this care for residents who cannot perform these tasks independently.
Resident #25 had been admitted to the facility from the hospital with multiple serious medical conditions. In addition to the stroke and its complications, the patient required specialized equipment for breathing and nutrition.
The diuretic medication made frequent incontinence care even more critical. Lasix forces the kidneys to remove excess fluid from the body, dramatically increasing urine production. The medication was prescribed for eight consecutive days, from November 17 through November 25.
The nursing home's own care plan acknowledged that Resident #25 needed repositioning every two hours at minimum. The plan also specified that staff could provide care more frequently when circumstances required it.
Despite these requirements, RN #21 left the stroke patient sitting in urine for at least 90 minutes while family members watched.
The complaint that triggered the federal investigation was filed on January 5, 2025, more than two months after the incident. State survey officials assigned it intake number MD00212895/358358 and forwarded it to federal inspectors.
Inspectors reviewed Resident #25's complete medical record on September 11, 2025, nearly ten months after the incident occurred. The review confirmed the details of the November 20 encounter between the family member and nursing staff.
The facility failed to provide activities of daily living care according to the resident's plan of care. Federal inspectors classified this as a violation that caused minimal harm or had the potential for actual harm.
Crescent Cities Nursing & Rehabilitation Center is located at 4409 East West Highway in Riverdale. The facility was surveyed as part of a complaint investigation completed on September 12, 2025.
The inspection found that few residents were affected by the deficiency in activities of daily living care. However, for Resident #25, the impact was immediate and undeniable.
A family member discovered their loved one sitting in urine during what should have been a routine visit. When they asked for help, nursing staff refused to provide basic care that the facility's own policies required.
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
- View all inspection reports for Crescent Cities Nursing & Rehabilitation Center
- Browse all MD nursing home inspections