Crown Pointe Care Center

In the surveyor’s words

From the most serious findings on record at Crown Pointe Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 10, 2023

  Based on medical record review, review of the facility's investigation, staff interview, review of the coroner's report, and review of the facility's policies, the facility failed to provide a resident with adequate supervision to prevent an avoidable fall and conduct a thorough root cause analysis of the circumstances surrounding the fall to prevent the same action, situations, and/or practices from occurring in the future. This resulted in Actual Harm to Resident #86 when State tested Nursing Aide (STNA) #130 stepped away from Resident #86 to obtain a blanket, leaving the resident alone in the shower chair when Resident #86 stoop up and subsequently fell , sustaining an acute intertrochanteric hip fracture requiring surgical repair. […]

• No harm, potential for more than minimal, widespreadF812Jul 28, 2025

  Based on observation, staff interview, and facility policy review, the facility failed to ensure staff wore hair nets in the kitchen as required. This had the potential to affect 88 residents in the facility. The facility identified one resident (#03) who did not receive food from the kitchen. The facility census was 89. 1. Observation on 07/23/25 at 7:20 A.M. revealed [NAME] #168 assisting [NAME] #119 with obtaining food temperatures on the steam table. [NAME] #168 was observed with braids which extended approximately 18 inches down her back and was not wearing a hair net. Observation on 07/23/25 at 7:36 A.M., [NAME] #168 was observed briefly leaving the kitchen and returned, wearing a hair net, however her braids still remained hanging outside of the hairnet. […]

• No harm, potential for more than minimal, widespreadF880Mar 13, 2024

  Based on review of monthly infection control surveillance logs, staff interview, and facility policy review, the facility failed to to maintain a complete and accurate tracking system for all infections. This had the potential to affect all 86 residents residing in the facility. The census was 86. Findings Include: Review of the facility infection control monthly surveillance log on 03/13/24 revealed the facility failed to document the results of cultures for residents with suspected or actual infections from May 2023 through February 2024. On 03/13/24 at 10:20 A.M., interview with the Director of Nursing (DON) and the Regional Nurse #200 verified the infection control log was not tracking the bacteria being treated for community acquired and facility acquired infections. […]

• No harm, potential for more than minimal, widespreadF812Aug 31, 2021

  Based on observations, staff interviews, and facility policy review, the facility failed to ensure food was prepared and served in a sanitary manner. This had the potential to affect all 80 residents who received food from the kitchen. Findings Include: 1. Observation of dining in the locked dementia unit on 08/23/21 at 12:27 P.M. during the lunch meal revealed Activities Aide (AA) #101 washed her hands at the sink and donned clean gloves. AA #101 was observed touching the handle of the serving cart with her gloved hands to wheel the resident's food around to the tables and serve the residents. […]

• No harm, potential for more than minimal, patternF690Feb 20, 2026

  Based on record review and interviews, the facility failed to ensure incontinent care was provided at least once every shift. This affected five (Resident #1, #2, #3, #4, and #17) out of nine residents reviewed for incontinence care. The facility census was 78.Findings include: 1. Review of the medical record revealed Resident #1 was admitted on [DATE] with diagnoses that included acute and chronic respiratory failure, cerebral infarction, hemiplegia and hemiparesis, aphasia, anxiety disorder, and benign prostatic hyperplasia. Review of Resident #1's care plan dated 05/08/24 revealed Resident #1 had alteration in elimination and required assistance with toileting. Interventions included to provide incontinence care as needed. […]