Cross City Nursing And Rehabilitation Center

Based on observation, interview, and record review the facility failed to ensure food was served in a sanitary manner during the 9/10/2025 midday meal, of two meals observed. Findings include:During an observation on 9/10/2025 beginning at 11:20 AM of the food services midday Staff A, [NAME] was observed using gloved hands to retrieve scoops, metal containers and other items from various areas in the kitchen. At 11:30 AM Staff A, did not remove the gloves or perform hand hygiene and lifted two pieces of cornbread from a metal tray with her gloved hands and placed the cornbread on individual residents' plates for service to the residents.During an interview on 9/10/2025 at 11:32 AM, the Certified Dietary Manager stated, She [Staff A] should use tongs to lift the cornbread from the tray and place on plates for service to residents.During an observation on 9/10/2025 at 11:34 AM, Staff A was observed lifting plates and bowls to fill with food for service to the residents. Staff A lifted two bowls and two plates with her fingers touching the interior food surface of the bowls and her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for 1 of 3 residents, Resident #51. Findings Include:Review of the Discharge/Return Anticipated/End of PPS [prospective payment system] Part A Stay MDS for Resident #51 dated 8/12/2025, read, Section A: Discharge Status: Home/CommunityReview of the census documented Resident #51 currently resides in the facility.During an interview on 09/09/2025 at 11:32 AM, Staff C, RN/MDS Coordinator (Registered Nurse) stated, He [Resident #51] was discharged , and we thought he was coming back. He went to an appointment on that day, was admitted to the hospital and we didn't have clear information on what was going on. We thought he was discharging home from the hospital. I didn't know if he was going to come back or not. Looking back on it, I should have coded the discharge status as 04. Short-Term General HospitalDuring an interview on 09/09/2025 at 1:04 PM, Resident #51 stated, I remember going to the hospital, but I don't remember the date. Review of the policy and procedure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the administration of insulin and to notify the physician of elevated blood glucose values for 2 of 5 residents, Residents #25 and #22) reviewed for unnecessary medications.Findings include: 1) Review of Resident #25's admission record documented diagnosis to include myocardial infarction type 2 (a heart attack), cognitive communication deficit, type 2 diabetes mellitus without complications, chronic atrial fibrillation (an irregular heartbeat), unspecified, essential (primary) hypertension (high blood pressure), hyperlipidemia, unspecified (high cholesterol), and atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain).Review of Resident #25's physician orders dated 9/4/2025 read, Insulin Glargine-yfgn [yfgn is a unique suffix identifier assigned by the U.S. Food and Drug Administration to distinguish it from other similar products]. Subcutaneous Solution Pen-injector 100 unit/ml (milliliter) (Insulin Glargine-yfgn) inject 63 units subcutaneously at bedtime…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to administer oxygen at physician ordered flow rates according to professional standards of practice for 2 (Resident #1 and #26) of 3 residents reviewed for oxygen administration. Findings include: 1) During an observation on 9/8/2025 at 10:00 AM Resident #1 was observed in bed. Oxygen was being administered via concentrator by nasal cannula at 4 liters per minute.Review of Resident #1's admission record documented diagnosis that include acute and chronic respiratory failure with hypoxia (a condition where the lungs are unable to exchange oxygen and carbon dioxide leading to low oxygen levels-hypoxia), chronic obstructive pulmonary disease (lung disease that cause breathing problems) with acute exacerbation (a sudden worsening of the symptoms), pneumonia, unspecified organism, and acute and chronic (systolic) congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should).Review of Resident #1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure physician ordered parameters were followed related to blood pressure medications resulting in the administration of unnecessary medications for 2 (Resident #16 and #35) of 5 residents reviewed for unnecessary medications.Findings include:1) Review of Resident #16's admission record documented diagnosis that include chronic obstructive pulmonary disease, unspecified, type 2 diabetes mellitus without complications, iron deficiency anemia, unspecified, vitamin b12 deficiency anemia, unspecified, chronic pain syndrome, major depressive disorder, recurrent, mild, unspecified atrial fibrillation (an irregular heartbeat), gastro-esophageal reflux disease without esophagitis, hyperlipidemia, unspecified (high cholesterol),and essential (primary) hypertension (high blood pressure).Review of Resident #16's physician order dated 4/27/2025 read, Labetalol HCl [labetalol hydrochloride] oral tablet give 150 mg (milligrams) by mouth two times a day hold if HR [heart rate] <60 bpm [less than 60 beats per minute], hold if BP [blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure assessments accurately reflect the resident's status for 1 (Resident #57) of 4 residents reviewed for discharge status. Findings include: Review of the admission record documented Resident #57 was admitted on [DATE] with diagnoses including surgical aftercare, type 2 diabetes mellitus, chronic kidney disease and hypertension. Review of the social services progress note dated 5/14/24 for Resident #57 read, Discharge note: Per family/resident request, resident to discharge 05/15/2024. Resident to discharge home. Son will pick up and transport home . Review of the discharge summary progress note dated 5/15/24 for Resident #57 read, Resident, who is alert and oriented, transferred by son to Appointment then will go home . Review of Resident #57's Minimum Data Set (MDS) Discharge Return Not Anticipated assessment dated [DATE] read, discharge date , 05/15/2024. Discharge Status, Critical Access Hospital. During an interview on 6/18/24 at 10:15 AM the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents received medication as per physician orders for 2 (Resident #25, #211) of 4 residents reviewed for pain medication administration and for 1 (Resident #160) of 3 residents reviewed for the care and treatment related to Peripheral Inserted Central Catheter (PICC) line dressings. Findings include: 1). Review of Resident #211's physician's order dated 6/4/2024 read, Acetaminophen Tablet Give 650 mg (milligrams) by mouth every 6 hours as needed for Mild Pain Do Not Exceed 3gm (grams) in 24 hours, pain scale 1-3 Review of Resident #211's Medication Administration Record (MAR) for June 2024 documented the resident received Acetaminophen 650 mg on June 14 at 4:15 AM with a pain level of 6. Review of Resident #211's physician's order dated 6/4/2024 read, Oxycodone HCI Oral Tablet 5 MG Give 1 tablet by mouth every 4 hours as needed for Pain related to chronic pain syndrome. Pain scale 4-10 Review of Resident #211's MAR for June…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to provide a safe, functional, and sanitary environment in the food preparation, storage, and sanitation area of the kitchen. Findings include: On 2/6/2023 at 9:20 AM, during a tour of the kitchen, the surveyor observed multiple areas of the ceiling with flaking and cracking appearance in the food prep area. The wall by the dishwashing machine had an area where the wall board was pulling away, creating a break in the moisture barrier. The walk-in freezer had a large buildup of ice on the floor under the condenser unit, creating a slipping or tripping safety hazard. The kitchen had 4 of 6 light fixtures with cracked or broken light coverings. During an interview on 2/6/2023 at 9:30 AM, the Certified Dietary Manager (CDM), verified the ceiling had a flaking and cracking appearance over the food prepping area, the wall at the dishwashing machine had an area where the wall board was pulling away, creating a break in the moisture barrier, and the freezer floor had a large buildup of ice on the floor under the condenser unit. The CDM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 15 reviewed residents, Resident #26 and Resident #15. Findings include: 1. Review of Resident #26's records revealed the resident was readmitted to the facility on [DATE] with the diagnoses including generalized anxiety disorder, Post Traumatic Stress Disorder (PTSD), and major depressive disorder. Review of Resident #26's Preadmission Screening and Resident Review (PASRR) dated 8/3/2020 did not reveal anxiety disorder, depressive disorder or PTSD under mental illness or suspected mental illness. During an interview on 2/8/2023 at 10:00 AM, the Social Services Director confirmed that Resident #26's PASRR dated 8/3/2020 did not denote Resident #26's pertinent diagnoses on page 2 of the PASSR. Review of the facility policy and procedure titled Resident Assessment- Coordination with PASARR Program reviewed on 1/4/2023 reads, Policy Explanation and Compliance Guidelines: 1. All…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medical records were accurate and complete for 4 of 29 residents, Residents #2, #18, #41 and #48. Findings include: 1. Review of Resident #2's admission record revealed the resident was admitted to the facility on [DATE] with a history of heart failure, unspecified dementia, unspecified severity, anemia, other specified anxiety disorders, chronic obstructive pulmonary disease, peripheral vascular disease, chronic kidney disease stage 3, other reduced mobility, zoster without complications, muscle weakness, altered mental status, unspecified dementia, unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #2's progress note dated [DATE] reads, Quarterly Assessment- Met with resident who was up in wheelchair, dressed, alert, and oriented with mild confusion and able to make needs known. Daughter present for care plan. resident and daughter has [Sic.] no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control practice standards during wound care to help prevent the possible development and transmission of communicable diseases and infections. Findings include: On 2/8/2023 at 9:13 AM, during an observation of Staff C, Licensed Practical Nurse (LPN), Unit Manager, and Staff D, Certified Nursing Assistant (CNA), providing wound care for Resident #11, Staff C performed hand hygiene and donned gloves. Staff C removed the soiled dressing from the resident's right heel wound. Staff C did not remove the soiled gloves and did not perform hygiene. Staff C cleansed the wound and patted it dry and completed the wound care and exited the room. After performing hand hygiene, Staff C gathered supplies to provide wound care to the resident's left heel. Staff C performed hand hygiene, entered the room, placed the wound supplies on the bedside table without applying a barrier. Staff C donned gloves and then placed a barrier on the bedside table and began to open the supplies and placed them…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.