Crescent City Skilled Nursing

F-F550).

7. Lack of in person RD oversight of the kitchen and residents with nutrition/hydration issues (Cross-Reference

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

F-F692: Substandard Care).

This failure to identify and prioritize care areas resulted in facilities' lack of identification of resident safety issues, developing a plan to correct identified issues, implementing the plan and monitoring the results. This failure had the potential for decreased quality of care, potential for harm and even death.

Findings:

A review of the QAPI committee sign in sheets indicated QAPI meetings took place on 2/28/23, 3/23/24, 4/27/23, 5/25/23, 7/20/23, 11/30/23, 12/21/23, 1/24/24, 2/28/24, 3/28/24, 4/18/24, and 5/23/24. The Medical Director was present on 2/28/23, 4/27/23, 7/20/23, 1/24/24, and 4/18/24. The meetings lasted one-half- hour, except on 11/30/23,12/21/23, 3/28/24, 4/18/24, and 5/23/24, the QAPI meetings lasted 15 min. The Medical Director was not present at the 11/30/2023 quarterly QAPI meeting.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of104 056296 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 A review of the facility's 2024-2025 Quality Assurance & Performance Improvement (QAPI), indicated: . Mission: Our mission is to consistently deliver high quality, person-centered care with dignity, respect, Level of Harm - Minimal harm or compassion, and integrity. We strive to enrich and enhance every life we touch . QAPI Plan: . Goal 2: the potential for actual harm facility will reduce the quality measure rate for falls with major injury 1.9 percent by 12/31/24 . Goal 4: The facility will decrease the number of falls by 50 percent. Goal 5: Call lights will be addressed within five Residents Affected - Some minutes or less by 12/31/2024 . Goal 13: ADL documentation: showers, meals all other ADLS .

During an interview on 6/21/24 at 12:30 p.m., the Director of Nursing (DON) stated the Fall Committee never got done. The DON stated the Administrator will not let her do her job duties as a DON. The DON stated she implemented a disciplinary action plan for all the call offs: 1. Verbal Warning, 2. Written Warning, 3. Suspension and 4. Termination. The DON stated the owner liked the frequent staff Call Off plan and asked for it to be implement at once. Fall Risk care plan should be updated right after accident. The resident should have a BM at least every 3 days.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of104 056296 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 During this interview with the DON on 6/21/24 at 5:01 p.m., she was asked if they had a QAPI project regarding weight loss issues for the residents. The DON stated the Assistant Director of Nursing was Level of Harm - Minimal harm or responsible for tracking information regarding this issue but had not provided her with any information to potential for actual harm enter into the QAPI plan. She presented the plan on her computer which was blank, as no data had been entered. The DON stated the Administrator was aware of the weight loss issues among the resident Residents Affected - Some population of the facility. The DON stated no decisions had been made as to what they were going to measure regarding weight loss issues, in the QAPI plan. The DON was also asked if they were tracking staffing issues in the QAPI plan. The DON stated staffing was not being tracked. The DON stated the Administrator was present in the QAPI meetings, but she (the DON) was the one coordinating the QAPI program, however, she was not being assisted by the Department Heads who were supposed to provide her with their reports, and she believed some Department Heads were not tracking any data.

During a phone interview on 6/24/24 at 1:46 p.m., Physician 1 stated he felt as if he had been attending QAPI quarterly. Physician 1 stated falls were a big issue that should be trended to see why the resident was falling, what time of day, interventions updated, etc. Physician 1 stated how QAPI was monitoring/tracking falls and implementing safeguards to decrease the number of falls occurring in the facility would be something to address with the Administrator. Physician 1 stated he was sympathetic regarding some of

these residents falling frequently because no matter what interventions you put in place the residents will still tend to fall. It was addressed to Physician 1, if a facility decided to admit a resident, was it not up to the facility to make sure the resident was safe and for a facility to have over 50 falls in a two-month period. The data on falls was not being analyzed for trends/similarities so there was a comprehensive data on why so many falls occurred in order to prevent falls and falls with injuries. Physician 1 stated, I agree. Physician 1 stated again, something to take up with the Administrator.

The facility policy and procedure titled, QAPI Policy & Procedure, dated 2022, indicated, Use this Plan-Do-Study-Act (PDSA) to plan and document your progress with tests of change conducted as part of chartered performance improvement projects (PIPs) . Remember that a PIP will usually involve multiple PDSA cycles in order to achieve your aim. Use as many forms as you need to track your PDSA cycles. Identify opportunities for improvement that exist (look for causes of problems that have occurred -see Guidance for Performing Root Cause Analysis with Performance Improvement Projects; or identify potential problems before they occur . Points where breakdowns occur . Identify better ways to do things that address

the root causes of the problem .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of104 056296 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 35842 potential for actual harm Based on interview and administrative document review, the facility failed to ensure it had an effective Residents Affected - Some Quality Assurance Performance Improvement (QAPI) program when the Medical Director or designee did not consistently attend meetings. This failure to have required committee members consistently attend meetings had the potential to result in lack of facility identification of significant resident safety issues, developing a plan to correct identified issues, implementing the plan, and monitoring the results which had the potential to affect the outcomes, dignity, and safety of facility residents.

Findings:

A review of the QAPI committee sign in sheets indicated QAPI meetings took place on 2/28/23, 3/23/24, 4/27/23, 5/25/23, 7/20/23, 11/30/23, 12/21/23, 1/24/24, 2/28/24, 3/28/24, 4/18/24, and 5/23/24. The Medical Director was present on 2/28/23, 4/27/23, 7/20/23, 1/24/24, and 4/18/24. The meetings lasted one-half- hour, except on 11/30/23,12/21/23, 3/28/24, 4/18/24, and 5/23/24, the QAPI meetings lasted 15 min. The Medical Director was not present at the 11/30/2023 quarterly QAPI meeting.

During an interview on 6/21/24 at 3:34 p.m., it was addressed to the Administrator per reviewing the QAPI sign in sheets, the Medical Director missed the 11/30/23, quarterly QAPI meeting. The last meeting the Medical Director attended was 7/20/23 and he did not attend another QAPI meeting until 1/24/24, which was six months later. The Administrator stated the Medical Director could have missed the QAPI meeting because of the weather preventing him from coming in.

The facility QAPI, dated 2024-2025, indicated: . Guiding principle #3: In our organization QAPI includes all employees all departments and all services .

The job description titled, Medical Director, revision 6/2012, indicated: . Agreement: 1. Duties and Obligations of Medical Director: . 1.5 Compliance with Facility's Policies and with Laws. Physician shall comply with and shall perform the Services in accordance with: (i) Facility's policies and procedures, including the Facility's Compliance Plan and Code of Conduct, (ii) all applicable local, state and federal laws and regulations; .

?

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 99 of104 056296 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 27532 potential for actual harm Based on observation, interview and record review, the facility failed to ensure staff practiced hand hygiene Residents Affected - Some and encouraged resident to wash or wipe their hands with wet washcloths before and after meals when:

1. Five residents (Resident 13, Resident 64, Resident 3, Resident 9, and Resident 63) were served their lunch trays without washing or wiping their hands clean before eating.

2. None of the residents in the social dining room were observed being reminded about hand sanitation prior to their meals, or provided hand sanitation supplies.

3. Staff used the same gloves while feeding three residents at the same time and staff helped various residents with their meals without hand sanitizing in between.

This failure can result in the spread of infection or an outbreak among the already frail health of the residents and staff in the facility.

Findings:

1. During an observation on 6/10/24, at 12:43 PM, a CNA was observed serving lunch to Resident 13 in his room. The CNA was not heard or observed to offer to wipe with a washcloth or wash the hands of Resident 13.

During an interview on 6/10/24, at 1:00 PM, Unlicensed Staff W stated they usually clean their residents in

the morning and the independent residents usually wash their hands. They usually do not offer to wash or wipe with wash cloths the hands of the residents before meals.

During a concurrent observation and interview on 6/10/24, at 01:01 PM, a CNA was not heart to offer to wash or wipe the hands of Resident 64 before serving his lunch tray. Resident 64 stated he was not asked to wash or wipe his hand with a washcloth before lunch.

During a concurrent observation and interview on 6/10/24, at 1:07 PM, A CNA served Resident 3 her lunch tray. The CNA did not offer to wash or wipe Resident 3's hands before giving her lunch tray. Resident 3 and her roommate Resident 65 stated CNAs never offer to wash resident's hands.

During an interview on 6/12/24, at 12:57 PM, when asked if the CNA who served her lunch tray offered to wash or wipe her hands before eating, Resident 9 stated, no.

During an observation 06/12/24 12:58 PM, Resident 13 was again not offered to wash or wipe his hands

before his meal.

During an interview on 6/12/24, at 12:59 PM, Unlicensed Staff X stated, she thought the other CNAs already offered sanitizing wipes before trays were offered. She did not offer anymore.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page100of104 056296 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 6/12/24, at 01:01 PM, Unlicensed Staff Y stated she had not offered to wash or wipe Resident 3's hands before her meal because she thought the CNA assigned to the hall already did it. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/12/24, at 1:02 PM, Unlicensed Staff D stated he was assigned to the North Hall but had not offered the sanitizing wipe to wipe the residents' hands before the trays were served because he Residents Affected - Some was busy. Unlicensed Staff D confirmed he had not offered to wash or wipe Resident 13's hands before his meal.

During a concurrent observation and interview on 6/12/24, at 1:05 PM, Unlicensed Staff Z, served Resident 63's lunch without officering to wash or wipe his hands with a washcloth. Unlicensed Staff Z stated he thought the CNA assigned to the hall already distributed the washcloths. Unlicensed Staff Z stated he had cleaned the hands of his residents especially those who needed help at his assigned hall before the trays were served.

39621

2. During a dining observation on 6/10/24 at 12:14 p.m., in the social dining room of the facility, the entire dining process was observed for lunch, from the time the residents were sitting in their tables, prior to being served their meals, to the time the meals were picked up by staff. At no point during the observation, were residents offered hand sanitizer or hand washing services. Their lunch meals on that day included a piece of bread that residents would touch with their bare hands. One of the staff members assisting residents with lunch in the social dining room was the Director of Staff Development (DSD).

During an interview in the social dining room of the facility on 6/10/24 at 1:11 p.m., Resident 61 and Resident 21 stated not having received reminders to wash their hands or offered hand sanitizer prior to having their lunch meal.

During an interview on 6/10/24 at 1:22 p.m., the DSD was asked if resident had received hand sanitation services prior to being served their lunch meals during the dining observation on 6/10/24. The DSD stated

she did not sanitize the residents' hands prior to being served their lunch meals.

During an interview with Resident 14 on 6/14/24 at 11:30 a.m., she stated facility staff had begun to provide them with hand sanitizer before meals after 6/10/24 (the day residents were observed not being offered hand sanitation services during lunch time), but during the weekend of 6/15/24 through 6/16/24, when the Surveyors were not in the facility, staff again did not offer hand sanitizer to the residents. According to Resident 14, hand sanitizer was offered to the residents prior to their meals only when the Surveyors were present.

35842

3. During a Total Assisted Dining (TAD) Room observation, on 6/10/24 at 12:18 p.m., there were eight residents and three staff members (Unlicensed Staff C, Unlicensed Staff E and a nurse) assisting the residents. Unlicensed Staff E was wearing gloves while he was feeding Resident 4 to his left and Resident 2 to his right.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page101of104 056296 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Resident 227 had arrived at the TAD Room and room was made for her to sit at the table next to Resident 2. Unlicensed Staff E, who was wearing gloves while feeding the resident on his left and the resident on his Level of Harm - Minimal harm or right, stopped feeding the two residents and went to help Resident 227 cut her meat while wearing the same potential for actual harm gloves. Unlicensed Staff E went back to feeding Resident 4 and Resident 2 without changing his gloves.

Residents Affected - Some Unlicensed Staff E got up from feeding Resident 4 and Resident 2 to give Resident 227 a bag of Cheetos. Unlicensed Staff E opened up Resident 227's Cheetos using the same gloves. Unlicensed Staff E used the same gloves while assisting and feeding Resident 4, Resident 2, and Resident 227.

Unlicensed Staff C was feeding Resident 52. After Licensed Staff C was done feeding Resident 52, Unlicensed Staff C started feeding Resident 55. Unlicensed Staff C did not sanitize her hands in between feeding the two residents.

Unlicensed Staff E was trying to wake up Resident 2 and touched her fork to give her a bite of meat using

the same gloves he was feeding Resident 4 with and assisting Resident 227. Unlicensed Staff E then assisted Resident 2 with her orange juice: held Resident 2's orange juice and her straw and placed the straw

in her mouth. Unlicensed Staff E then started to feed Resident 4 ice cream. Unlicensed Staff E then held the left arm of Resident 4's wheelchair to direct her back to the table. Unlicensed Staff E never changed his gloves throughout the meal.

Unlicensed Staff C picked up a few of the meal trays on table and placed them in the meal cart. Unlicensed Staff C then went back to feeding Resident 55 without sanitizing her hands. Unlicensed Staff C picked up two juices on the table and gave one of the juices to the nurse feeding a resident and gave the other juice to Resident 55. Unlicensed Staff C had not sanitized her hands in between assisting/feeding residents.

During TAD Room observation on 6/12/24 at 12:26 p.m., a nurse and Unlicensed Staff C passed out the resident meal trays and set-up residents for lunch, but no hand hygiene was offered prior to the residents' lunch. Prior to lunch, Resident 29 had been playing with a balloon other residents and staff had been touching but no hand hygiene was offered prior to her lunch. Resident 29 was blind, and her primary language was Spanish. Resident 29 was set-up for lunch but no staff member in the TAD Room spoke Spanish nor did any staff member assist Resident 29 on placement of where her food was on her plate and tray, so Resident 29 ate her pasta with her uncleaned fingers. Resident 29 was not offered hand hygiene

after eating her pasta with her fingers.

During an interview on 6/12/24 at 12:37 p.m., Unlicensed Staff C was asked if the residents in the TAD Room received hand hygiene before their lunch. Unlicensed Staff C state, Good question. None of the residents in the TAD Room were offered hand hygiene before lunch.

During an interview on 6/12/24 at 1:10 p.m., Unlicensed Staff D was asked if residents were offered a washcloth to wash their hands and face before meals. Unlicensed Staff D said, You mean to offer each resident a washcloth before each meal? When responded to in the affermative, Unlicensed Staff D said, That did not happen, offering each resident a washcloth to wash their face and hands before each meal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page102of104 056296 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 6/13/24 at 2:30 p.m., Unlicensed Staff C stated the HCP (Health Care Personal) were not trained to assist or give each resident a washcloth before and after each meal to wash their hands and Level of Harm - Minimal harm or face. Unlicensed Staff C stated if an HCP were feeding multiple residents at the same time with the same potential for actual harm gloves that could cause cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). Unlicensed Staff C stated hand sanitizing one's hands in between Residents Affected - Some assisting residents in the TAD Room was missed because the hand sanitizer dispenser was on the wall in

the hallway right of the door. There was no hand sanitizer dispenser inside the TAD Room.

During an interview on 6/14/24 at 11:15 a.m., the Infection Preventionist (IP) stated a Certified Nursing Assistant (CNA) should not be feeding three residents in the TAD Room with the same gloves. 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. The IP stated each resident should be offered hand washing before each meal. The IP stated there were anti-bacteria wipes and hand sanitizer to offer the residents who were in the dining rooms. The IP stated it was difficult to keep the dining rooms sanitized when giving residents warm wash cloths so anti-bacteria wipes were offered instead.

A review of the facility's policy titled, Hand Hygiene, last revised on 12/31/21, indicated, the facility considers hand hygiene the primary means to prevent the spread of infection. Facility staff follow the hand hygiene procedure to help prevent the spread of infections to other staff, residents, and visitors. Facility staff, visitors, and volunteers must perform hand hygiene procedures before eating. The policy did not specify for staff to offer or help residents wash or wipe their hands before and after eating.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page103of104 056296 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 17065 potential for actual harm Based on general kitchen observation and maintenance staff interview the facility failed to maintain the Residents Affected - Few physical environment of dietetic services as evidenced by standing water in one of the floor drains and missing tiles in the dry storage area.

Findings:

It would be the standard of practice to ensure floors are constructed of smooth and durable surfaces to allow for easy cleaning (USDA Food Code, 2022).

During general kitchen observation on 9/17/24 beginning at 9:30 a.m., it was noted there was a significant amount of water on the floor in front of the 3-compartment sink adjacent to the dish machine. It was also noted there was a floor drain that was filled with water, some of which was overflowing onto the floor. It was also noted there were missing floor tiles, that contained food debris, in the upper right-hand corner, underneath the wire shelving in the dry storage area.

In a follow up observation on 9/18/24 at 4 p.m., in the presence of Maintenance Staff (MS) the surveyor asked him to evaluate the drainage issue in the floor drain. MS agreed there should be no standing water in

the floor drain and it likely needed to be cleaned out. MS also stated he was unaware of the issue and relied

on dietary staff to notify him when there are maintenance issues. Review of dietary cleaning checklist, dated September 2024, failed to include the floor drains. Similarly, the departmental document titled Sanitation and Food Safety Checklist, dated 8/6 and 8/30/24 and completed by the Registered Dietitian, failed to include evaluation of the cleanliness of the floor drains. It was also noted the missing floor tiles were not identified as

an issue.

Departmental policy titled Sanitation dated 2023 indicated it was the responsibility of the DFS to notify any maintenance issues to the maintenance department who will assist food and nutrition staff in maintaining equipment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page104of104 056296

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