Crescent Cities Nursing & Rehabilitation Center

F 0552

Ensure that residents are fully informed and understand their health status, care and treatments.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on reviews of a complaint, a closed medical record, and interview with facility staff, it was determined that the facility failed to notify a resident's representative of 1) the risk and benefits of a surgical procedure and 2) to seek permission to perform the surgical procedure. This was evident for 1 (Resident #25) of 30 residents reviewed during a complaint survey. The findings include:Review of the complaint #MD00212895/358358

on 9/11/2025, revealed an allegation Resident #25's responsible party was not notified in advance of a wound care nurse practitioners plan to perform a debridement of Resident #25's sacral wound and bilateral heel wounds.Review of Resident #25's closed medical record on 09/11/2025 revealed Resident #25 was admitted to the facility on [DATE REDACTED] with diagnoses that included but not limited to a cerebrovascular accident with right side weakness, aphasia, dysphagia, cognitive communication deficit, a sacral pressure ulcer, and

a feeding tube placement. Resident #25 was totally dependent upon the facility staff for aspects of his care.A Braden Scale assessment involves evaluating a patient across six subscales-sensory perception, moisture, activity, mobility, nutrition, and friction/shear-to determine their risk for pressure injuries. A lower total score indicates a higher risk, with specific score ranges defining levels from No Risk to Severe Risk. A Braden wound assessment was completed on 12/05/2024 that indicated Resident #25 was assessed to be

a moderate risk for developing pressure ulcers (14/15).On 12/24/2024 at 7 pm, Resident #25 was assessed by the facility nurse practitioner wound consultant who documented Resident #25's sacral wound was surgically debrided and that consent for the procedure was obtained from Resident #25's spouse. The nurse practitioner wound consultant also documented that he/she provided the potential risks and benefits including but not limited to scar formation, bleeding, and infection were reviewed with Resident #25's family.Further review of Resident #25's closed medical record revealed that on 02/18/2025, the facility nurse practitioner wound consultant surgically debrided both Resident #25's right and left heels. The facility nurse practitioner wound consultant again documented Potential benefits and risks including but not limited to scar formation, bleeding, and infection were reviewed with facility staff. The facility nurse practitioner wound consultant again documented that he/she confirmed consent was obtained verbally for wound debridement from Resident #25's spouse.In an interview with the facility nurse practitioner wound consultant on 09/12/2025 at 2:30 PM. The facility nurse practitioner wound consultant stated that he/she had spoken to Resident #25's responsible party after admission via a telephone call in November 2024.

The facility nurse practitioner wound consultant stated that a general consent to treatment is obtained

during the admission process. The facility nurse practitioner wound consultant stated that he/she had not spoken to Resident #25's responsible party the day of or just before performing the surgical debridement of Resident #25's sacrum in December 2025 nor the surgical debridement of Resident #25's bilateral heels in February 2025.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crescent Cities Nursing & Rehabilitation Center

4409 East West Highway Riverdale, MD 20737

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 0569

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Level of Harm - Minimal harm or potential for actual harm

Based on reviews of a complaint, a closed medical record and a patient fund account, and interviews with facility staff, it was determined that the facility staff failed to disperse the remaining account funds to a discharged resident (Resident #23) within 30 days. This is evident for 1 of 30 residents reviewed during compliant survey. The findings include:Review of complaint MD00213913/358365 on 09/10/2025 revealed and allegation Resident #23 had not received the remaining disbursement of funds after being discharged from the facility. Resident #23 alleges that there is $2,513.14 the facility is still holding from in his/her patient fund account. A review of Resident #23's closed medical record on 09/10/2025 revealed that Resident #23 was discharged from the facility on 03/31/2025. A review of Resident #23's financial summary on 09/10/2025 at 3:03 PM revealed a sum of $1,920.96 is currently owed to Resident #23 from the facility.In an

Interview with the facility Administrator and Business Office Manager (BOM) on 09/10/2025 at 3:03 PM, the facility BOM confirmed that Resident #23 was discharged from the facility on 03/31/2025. The facility BOM also stated that s/he submitted the wrong form to the corporate office to have Resident 23's remaining funds disbursed. The facility BOM stated that Resident #23's refund has not gone out yet.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crescent Cities Nursing & Rehabilitation Center

4409 East West Highway Riverdale, MD 20737

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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on reviews of a complaint, a closed medical record, and all pertinent administrative records and staff interview,

it was determined that the facility staff failed to immediately notify a resident's physician and responsible party regarding a change in condition on 07/06/25 at 3 AM. This was evident for 1 (Resident #15) of 30 residents reviewed during a complaint survey.The findings include:The facility staff failed to immediately notify Resident #15's physician and representative when Resident #15 had an unwitnessed fall with injury

on 07/06/25 at 3 AM.Review of complaint 2580338 on 08/21/25 revealed an allegation Resident #15 had been abused by the facility staff on 07/06/2025.Review of Resident #15's closed medical record on 08/21/25 revealed the Resident was admitted to the facility on [DATE REDACTED] with diagnoses that include pneumonia, respiratory failure and vascular dementia. Dementia is a general term for a decline in mental ability severe enough to interfere with daily life. Resident #15 also only spoke Spanish as his primary language.A review of nursing progress notes dated 07/06/2026 at 3:59 AM, LPN #19 (staff member #19) documented that Resident #5 had an unwitnessed fall after trying to use the restroom without calling for assistance. LPN #19 documented Resident #15 had skin tears after the fall. LPN #19 failed to notify Resident #15 physician and representative at this time of the injuries sustained with the fall.Further review of Resident 15's medical record revealed no notification to the Resident's representative when the fall with injury occurred on 07/06/2025 at 3 AM.Interview with the Director of Nursing on 09/12/25 at 4:20 PM confirmed the facility staff failed to immediately notify Resident #15's representative when Resident #15 had a fall with injury on 07/06/2026 at 3 AM.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crescent Cities Nursing & Rehabilitation Center

4409 East West Highway Riverdale, MD 20737

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

stated that Resident #15's daughter found her relative with bleeding arms and a laceration. I spoke to the nurse and asked the nurse to take pictures of Resident #15's arms and send them to me on 07/06/2025.

The daughter called the police to find out why there was blood outside the resident's bathroom. The staff spoke about the incident regarding Resident #15 on the next Monday and I requested that the facility Administrator investigate the incident.A review of the facility nursing investigative form on 08/21/2025 revealed the facility Director of Nurses (DON) investigated Resident #15's bilateral skin tears to both arms and indicated the injuries were caused by an unwitnessed fall. Staff found Resident #15 on the floor of the room on 07/06/2025 at approximately 3 AM during routine rounds. The facility DON indicated that the local State Agency (OHCQ) was not notified of the incident. A review of Staff member #19's un-witnessed fall incident note, dated 07/06/2025 at 3:10 AM, revealed that after finding Resident #15 on the floor, Resident #15 was noted to be alert, but disoriented and had a BIMS score of 0. Staff member #19 also documented that Resident #15 was also observed with subsequent skin tearing on both sides post fall. Staff member #19 noted predisposing physiological factors to Resident #15's fall were: confusion, gait imbalance, recent changes in cognition, and recent illness. 2) The State Survey Agency (SA) received a complaint on 12/20/2024 (Intake MD00212895/358358) with complainant allegations indicating that Resident #25's had been abused by the facility staff. Resident #25's was found with bruising on his/her back right shoulder area.A review of Resident #25's closed medical record on 09/11/2025 revealed Resident #25 was admitted from the hospital on [DATE REDACTED] with diagnoses that include cerebrovascular accident with right side weakness, percutaneous gastrostomy tube (feeding tube), and a tracheostomy. Resident #25 is nonverbal and totally dependent upon the nursing staff for all of his/her care needs.In an interview with RN #21 (staff member #21) on 09/11/2025 at 3:10 PM, RN #21 stated that Resident #25's bruising to his/her right back shoulder was non-blanchable and a skin decolorization and that Resident #25 was unable to tell the staff what happened. RN #21 stated it was an unknown bruise and not sure if the facility conducted an investigation into Resident #25's bruise of unknown source. RN #25 stated a family member brought Resident #25's right back bruise to his/her attention and confirmed the GNA staff had not informed RN #21 of Resident #25's right back bruise on 12/20/2024.In an interview with the facility administrator on 09/12/2025 at 2:05 PM, the facility administrator stated the facility did not investigate Resident #25's bruising to the right back shoulder because the bruise was pressure not trauma.The facility failed to conduct an investigation into a bruise of unknown source that was identified on 12/20/2024 with a resident that was unable to inform staff of how he/she received the bruising.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crescent Cities Nursing & Rehabilitation Center

4409 East West Highway Riverdale, MD 20737

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 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on reviews of a complaint, a resident's closed medical records, and staff interviews, it was determined that the facility staff failed to provide activities of daily living (ADL) care in accordance with the resident's plan of care. This was found to be evident for 1 (Resident #25) of 30 residents reviewed during a complaint survey.The findings include: Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, toileting, bathing, and mobility.The State Survey Agency (SA) received an additional complaint on 01/05/2025 (Intake MD00212895/358358) with complaints indicating that Resident #25's had not received incontinence care timely. A review of Resident #25's closed medical record on 09/11/2025 revealed Resident #25 was admitted from the hospital on [DATE REDACTED] with diagnoses that include cerebrovascular accident with right side weakness, percutaneous gastrostomy tube (feeding tube), and a tracheostomy. Resident #25 is nonverbal and totally dependent upon the nursing staff for all of his/her care needs.On 11/16/2024, Resident #25's physician wrote an order for a chest x-ray which showed Resident #25 suffered from mild congestive heart failure and interstitial edema. Resident #25's physician started Resident #25 on the diuretic, Lasix, 20 milligrams, via g-tube, daily for 8 days (11/17/24 through 11/25/2024).On 11/20/2024 at approximately 2:30 PM, a family member was visiting Resident #25 and noticed that Resident #25 was incontinent of urine. The family member requested assistance from the nursing staff for incontinence care. Resident #25's family member was told by RN #21 that Resident #25 had just had incontinence care at 1 PM and that Resident #25 had to wait until the next shift arrived at 3 PM because the GNA staff had left for the day.In an interview with RN#21 on 09/11/2025 at 4:12 PM, RN #21 stated that s/he recalled the day in November 2024 when Resident #25's family member asked for assistance with incontinence care for Resident #25. RN #21 stated that Resident #25's care plan indicates that s/he will be turned and repositioned minimally every 2 hours.

RN #21 also stated that the nursing staff can provide care more often if necessary. RN #21 stated that Resident #25 was provided incontinence care after 3 PM by the evening shift nursing staff on 11/20/2024.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crescent Cities Nursing & Rehabilitation Center

4409 East West Highway Riverdale, MD 20737

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

weights revealed:02/03/2025, 9:40 PM - 147 pounds02/04/2025, 1:49 pm - 147.2 pounds02/19/2025, 2:24 pm - 134 pounds02/24/2025, 11:42 am - 120.4 pounds Further review of Resident #21's closed medical

record failed to reveal a detailed progress note from the facility dietician addressing Resident #21's poor oral intake and weight loss. In an interview with the facility administrator on 09/03/2025 at 3:03 PM, the facility administrator stated that the facility dietician that was working in January 2025 no longer works at

the facility. Several attempts were made to call the dietician for an interview during the complaint survey without success.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crescent Cities Nursing & Rehabilitation Center

4409 East West Highway Riverdale, MD 20737

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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

gastrostomy tube (feeding tube), and a tracheostomy. Tube feeding and water flushes were initiated upon admission to the facility. On 12/20/2024 Resident #25's physician instructed the nursing staff to administer

the tube feeding, Glucerna 1.5 to run at 50 milliliters/hour for 24 hours. On 12/20/2024, Resident #25's physician also gave orders instructing the nursing staff to Hold Resident #25's tube feeding for 2 hours if residual volumes are above 500 mls. Resume tube feedings when residuals are below 500 mls every shift.

Further review of Resident #25's closed medical record, the nursing staff failed to document tube feeding residuals since admission to the facility.3) A review of Resident #26's medical record on 09/12/2025 revealed Resident #26 was admitted from the hospital on [DATE REDACTED] with diagnoses that include but are not limited to Encephalopathy, Dysphagia, Nontraumatic subdural hemorrhage, Gastrostomy status (feeding tube), COPD, Personal history of TIA and cerebral infarction without residual deficits, adult failure to thrive, Malignant neoplasm of right breast. On 06/11/2025, Resident #26's physician instructed the nursing staff to instruct the nursing staff to check for residuals prior to tube feeding administration. If it is greater than 120 ml, hold feeding for 1 hour and recheck. If residual amount is again over 120 ml call physician. Further

review of Resident #26's medical record, the nursing staff failed to document tube feeding residuals in September 2025. 4) A review of Resident #27's medical record on 09/12/2025 revealed Resident #27 was admitted from the hospital on [DATE REDACTED] with diagnoses that include but are not limited to homelessness, Dysphagia, Gastrostomy status (feeding tube), digestive surgery, and COPD. On 06/11/2025, Resident #27's physician instructed the nursing staff to instruct the nursing staff to check for residuals prior to tube feeding administration. If it is greater than 120 ml, hold feeding for 1 hour and recheck. If residual amount is again over 120 ml call physician. Further review of Resident #27's medical record, the nursing staff failed to document tube feeding residuals in September 2025. 5) A review of Resident #28's medical record on 09/12/2025 revealed Resident #28 was admitted from the hospital on [DATE REDACTED] with diagnoses that include but are not limited to Dysphagia, Gastrostomy status (feeding tube), adult failure to thrive, respiratory failure with hypoxia, and dementia. On 06/11/2025, Resident #28's physician instructed the nursing staff to instruct

the nursing staff to check for residuals prior to tube feeding administration. If it is greater than 120 ml, hold feeding for 1 hour and recheck. If residual amount is again over 120 ml call physician. A review of Resident 28's Care plan for Tube Feedings on 09/12/2025 revealed that the tube feeding care plan was initiated on 09/26/2021 and revised on 03/25/2025 and included a nursing intervention to: Check for tube placement and gastric contents/residual volume per facility protocol and record. Further review of Resident #28's medication administration record (MAR), revealed that the nursing staff failed to document Resident #28's tube feeding residuals in September 2025. In an interview with the facility administrator on 09/12/2025 at 3:38 PM, the nurse surveyor requested the facility tube feeding care policy. At 4:20 PM on 09/12/2025, a

review of the tube feeding policy was reviewed with the director of Nurses and the facility staff development coordinator (SDC). The SDC confirmed that if a resident is receiving tube feeding skilled services the nursing staff should be documenting tube feeding residuals in the medical record per physician order.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crescent Cities Nursing & Rehabilitation Center

4409 East West Highway Riverdale, MD 20737

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 0757

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by crushing a medication that should not be crushed. This was evident for 2 (Residents #19, #7) of 30 residents reviewed during a complaint survey. The findings include:1) Review of complaint MD00218857/358373 on 09/08/2025 revealed allegations that Resident #19 did not receive quality care during his/her stay.Review of Resident #19's closed medical record on 09/08/2025 revealed the Resident #19 was admitted to the facility on [DATE REDACTED] from the hospital with diagnoses that included a gastrostomy tube, congestive heart failure, and protein-calorie malnutrition. On 05/02/2025, Resident #19's physician gave orders to the nursing staff to obtain a weight, 3 times a week,

on Resident #19, and notify the physician if there is a 2-pound increase in weight. On 09/08/2025 at 12:43 PM a review of Resident #19's medical record was conducted.Review of Resident #19's May 2025 Medication Administration Record (MAR) documented the medication Jardiance 10 mg tablet, give once a day via feeding tube for diabetes. This order was written on 04/30/2025. A google search on 09/08/2025 revealed that the medication Jardiance should not be crushedIn an interview with Resident #19's physician

on 09/08/2025 at 2:15 PM, Resident #19's physician that the medication Jardiance should not be crushed and administered through a feeding tube.2) A review of Resident #7's medical record on 08/19/2025 at 3:45 PM revealed a physician's order instructing the nursing staff to administer the medication Melatonin 1 milligram by mouth at bedtime for insomnia. Resident #7's physician also gave an order, dated 01/29/2025, to monitor Resident #7 for behaviors of: exit seeking, increase in complaints, kicking, cussing, non-adherence to the smoking policy, and refusing care. Document N if none of the above observed.

Document Y if any of the above was observed, select chart code Other/See nurses notes and note findings every shift. Document behavior, interventions and outcomes in progress notes. Further review of Resident #7's August 2025 Medication Administration Record (MAR) revealed that on 08/12/2025, during the evening shift, the nurse documented YES under behaviors. Further review of Resident #7's 08/12/2025 nursing progress notes failed to reveal any description of the behavior observed during the shift, the nursing interventions and outcomes of Resident #7's behavior.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crescent Cities Nursing & Rehabilitation Center

4409 East West Highway Riverdale, MD 20737

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaints, reviews of a closed medical record and staff interview, it was determined that the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for ?????? (Residents #15) of 30 residents reviewed during a complaint survey.The findings include.A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.1) The State Survey Agency (SA) received a complaint on [DATE REDACTED] (Intake 2580338) with allegations indicating Resident #15 had been abused by the facility staff. A review of Resident #15's closed medical record on [DATE REDACTED] at 1 PM revealed that Resident #15 was admitted to the facility on [DATE REDACTED].

Resident #15's closed record was reviewed on [DATE REDACTED] which revealed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form was completed on [DATE REDACTED] by a hospital physician. The front page of the MOLST form indicated that Resident #15 and his guardian's wished to be a No CPR, DNI (do not intubate) option A-2 for life sustaining care. The back page was not completed. Further review revealed a [DATE REDACTED] physician order that indicated Resident #15 was to be a Full Code/CPR. Review of Resident #15's basic admission care plan also revealed an Advance Directive Care Plan Indicating Resident #15 wished to be a Full Code/CPR. A set of advance directives was not available for review in Resident #15's closed medical record.

Event ID:

Facility ID:

If continuation sheet