Crystal Cove Post Acute

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Mar 12, 2025

  Based on interview and record review the facility failed to ensure staff performed Cardio-Pulmonary Resuscitation (CPR/an emergency procedure consisting of chest compressions combined with giving breaths of air) and failed to assure required staff had unexpired CPR certifications for 1 of 1 resident (Resident 1) who was found unresponsive and had a physician's order for CPR. The failure of facility staff to initiate CPR placed all residents who chose to have CPR initiated at risk for serious injury, harm, impairment or death and represented an Immediate Jeopardy (IJ) situation. On [DATE] at 2:45 PM, the facility was notified of an IJ at CRF 483.24 (a)(3), F678 CPR, the IJ was determined to have begun on [DATE] when the facility failed to perform CPR. […]

• Immediate jeopardy, isolatedF684Aug 19, 2024

  Based on observation, interview and record review the facility failed to provide timely assessment and treatment by a qualified professional in response to a significant and acute change in condition for 1 of 3 residents (Resident 5) reviewed for death in the facility. Resident 5, who had a recent history of aspiration (inhalation of foreign material into the lungs), experienced harm when they vomited, and experienced a sudden change in breathing pattern with bluing around the lips and eventually expired. […]

• Actual harm, isolatedF684Jun 2, 2026

  Based on interview and record review, the facility failed to timely recognize and respond to an acute clinical change in condition, contact on-call clinical leaership if the resident's condition does not clearly support in-house monitoring, and contact emergency medical services timely when the resident's condition appeared unstable or life threatening for 1 of 3 residents (Resident 1) reviewed for an acute change of condition. Resident 1 experienced harm when the facility delayed obtaining emergency medical services and access to a higher level of care despite signs and symptoms consistent with a significant change in neurological status. The resident was subsequently transferred to the hospital where they were diagnosed with a non-operable intracranial hemorrhage (brain bleed). […]

• Actual harm, isolatedF689Jan 2, 2026

  Based on observation, interview, and record review, the facility failed to provide staff supervision and implement fall prevention strategies for a resident assessed at high fall risk for 1 of 3 residents (Resident 1) reviewed for falls. Resident 1, who had at least three prior unwitnessed falls from their bed, experienced harm when they were positioned on the edge of their bed unsupervised, was subsequently found on the floor and required transfer to the hospital where they were diagnosed with multiple fractures at the right wrist. This failure placed resident at risk for falls, injury and decreased quality of life. […]

• Actual harm, isolatedF686Feb 7, 2025

  Based on observation, interview and record review, the facility failed to ensure adequate care and services were provided to promote wound healing and prevent pressure ulcers from developing or worsening by implementing and following care interventions timely for 4 of 7 sampled residents (Residents 1, 2, 5 and 6) reviewed for pressure ulcers. Resident 1 experienced harm when the resident's skin was not assessed, and they developed an unstageable pressure ulcer to the left heel with no treatment initiated for 12 days. […]