Crystal Cove Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jun 8, 2021

  Based on observation, interview, and facility P&P review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen as evidenced by: * The facility failed to ensure meat was properly thawed using the sink thawing method. * The facility failed to ensure a proper sanitary condition of the ice machine. * The facility failed to ensure food preparation equipment was clean. * The facility failed to ensure that a wooden table used in the kitchen for food preparation was cleanable. […]

• No harm, potential for more than minimal, patternF755Jun 19, 2026

  Based on interview, medical record review, and facility P&P review, the facility failed to follow the physician's orders for one of five final sampled residents (Resident 12) reviewed for unnecessary medications and failed to follow safe medication storage and destruction practices for used controlled medicated patches. * Resident 12's blood pressure medications were not administered as ordered. * The DON did not wear gloves when handling used fentanyl patches medication. Additionally, the fentanyl patches medication were stored in open packages, there were missing patches, and the accompanying narcotic sheet counts were not readily available. […]

• No harm, potential for more than minimal, patternF761Jun 19, 2026

  Based on observation, interview, and medical record review, the facility failed to ensure processes for labeling and storing biologicals were maintained. * Resident's 28 Liraglutide (insulin) pen injector label showed to administer 1.8 mg while the physician's order showed to administer 1.2 mg of Liraglutide. * The enteral feeding storage area did not have a thermometer or temperature log to ensure the enteral feedings temperatures were being maintained at room temperature. These failures had the potential for the residents to not receive the correct dosage of insulin and for enteral feedings to not be stored at appropriate temperatures, potentially compromising resident safety and care.Findings: 1. On 6/17/26 at 0916 hours, a medication administration observation was conducted with LVN 4. […]

• No harm, potential for more than minimal, patternF812Jun 19, 2026

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed. * The facility failed to ensure food preparation equipment was air dried. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population for 77 out of 82 residents that consumed food prepared in the kitchen.Findings: According to the FDA Food Code 2022, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganisms can begin to grow. […]

• No harm, potential for more than minimal, patternF813Jun 19, 2026

  Based on observation, interview, and facility P&P review, the facility failed to ensure food brought to the facility from outside sources for the resident consumption was properly stored. * The facility failed to ensure multiple food items were labeled, dated, and discarded before the use-by date. These failures had the potential to expose the residents who received food brought from the outside to food borne illnesses. Findings: Review of the facility's P&P titled Foods Brought by Family/Visitors dated 1/2025 showed food brought in by family visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility prepared food. Non-perishable foods are stored in re-sealable containers with tight fitting lids. […]