Crescent City Care Center

F-F584), residents did not receive the care and services they needed (

F-F658). In addition, despite inadequate staffing levels, they continued to accept new residents (

F-F677).

3.

Lack of monitoring falls in 2024, Falls with injuries: the facility had one in 4/2024, one in 5/2024, and one in 6/2024.

Total number of falls: 28 (January), 34 (February), 35 (March), 12 (April), and 25 (May) (Cross-Reference

F-F689 - Substandard Care).

2.

The Administrator did not ensure the RD (Registered Dietician) was making frequent scheduled visits to oversee the day-to-day operations of the kitchen, which led to multiple issues in the kitchen including errors in plating prescribed diets and lack of dietary staff competencies in the cool down process, thawing process and three sink washing process.

Failure to ensure adequate oversight may result in compromising the nutritional status of all residents and cross contamination of resident food and foodborne illness (Cross-Reference

During a phone interview on 6/21/24 at 2:15 p.m., Physician 1 stated he came to the facility monthly and attended the QAPI meetings.

Physician 1 stated falls were reviewed and weight issues were monitored.

Physician 1 stated the (Registered Dietician) RD made the recommendations which Physician 1 approved and Physician 1 would order medications to improve the resident's appetite such as Remeron (treats depression and causes weight gain).

Physician 1 stated the resident population in the community was challenging and staffing was a challenge.

Physician 1 felt the resident's needs were being addressed.

Physician 1 was asked severely times about what has the QAPI Committee implemented to promote fall prevention in order to keep the residents safe and what was the Weight Variance Committee bring to QAPI Committee to decrease the percentage of nutritional issues such as severe weight loss and gain.

Physician 1 felt the residents' needs were being addressed and he felt the staff were doing a good job regarding weight loss.

Physician 1 felt surveyors were not looking at the big picture when discussing weight loss/gain and falls.

Physician 1 stated, You are not looking at the Forest through the Trees.

During an interview with the DON on 06/21/24 at 5:01 p.m., the QAPI program was presented and discussed.

The DON stated Department Heads within the facility were supposed to bring reports to her of resident concerns or issues, to enter into the QAPI system but they were not bringing the reports.

The DON stated she bought a screen and a projector for this purpose, but they were inefficient, as there was insufficient participation by Department Heads.

When asked about the number resident falls at the facility, the DON stated there had been 28 falls in January 2024, 34 falls in February 2024, 35 falls in March 2024, 12 falls in April 2024 and 25 falls in May 2024, for a total of 134 falls for the first five months of the year.

Three of these falls resulted in major injuries.

The DON stated that although the number of falls were being tracked, interventions for fall prevention measures were not being tracked.

The DON stated Department Heads had not had a meeting specifically to discuss falls and decide what they were going to do to reduce the incidences of falls.

The fall QAPI project presented to the Surveyors through the DON's computer had several areas that were blank or empty.

056296

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056296 B.

Wing 06/21/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crescent City Skilled Nursing 1280 Marshall Street Crescent City, CA 95531

F-F725), meals were not palatable, stored or prepared in a sanitary manner (

F-F761) and resident care plans were not created or revised (

F-F812).

3.

The Administrator did not ensure the RD made routine visits to residents with significant weight loss or gain in order to observe/interview residents to find out why they were having severe nutritional changes, and make sure new admission's nutritional assessments were done in person to minimize nutritional complications.

This resulted in multiple residents, including Resident 12, Resident 20. Resident 25, Resident 29, and Resident 227, having various nutritional complications leading to further compromising the resident's medical state (Cross-Reference 692 - Substandard Care).

4.

The Administrator did not ensure there were staff in sufficient numbers to meet the individual care needs of residents resulting in residents having to wait long periods for call lights to be answered and lack of ADLs (Activities of Daily Living: are activities related to personal care.

They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and assisted with eating or needing to be fed), which led to a resident being left in a soiled brief for a long period causing breakdown in the resident's skin, lack of dignity for multiple residents, and had the potential for residents to become dehydrated and weight loss to occur because of not being offered water and assistance during meals or with snacks, feeling unkept and unclean, loss of self-worth and feeling of low self-esteem, which could further impacting residents' physical and psychosocial wellbeing.

Residents impacted included Resident 2, Resident 3, Resident 4, Resident 6, Resident 12, Resident 14, Resident 20, Resident 21, Resident 25, Resident 29, Resident 35, Resident 40, Resident 46, Resident 50, Resident 55, Resident 58, Resident 65, Resident 67, Resident 68, and Resident 232, but not limited to (Cross-Reference

F-F842).

5.

Lack of monitoring to make sure residents were being treated with dignity and respect (Cross-Reference

F-F865).

4.

Lack of monitoring documentation of meal and fluid intake.

Multiple residents with significant weight loss (Cross-Reference

F-F8800.

2.

Lack of monitoring of Activities of Daily Living (ADL) to ensure residents were receiving two showers a week, and the documentation appropriate and accurate (Cross-Reference