Crystal Creek Post-Acute

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 30, 2026

  Based on observation, interview, and record review, the facility failed to ensure safety measures were in place while providing care for one of three sampled residents (Resident 2), when:1. During a change of bedding, without securing Resident 2's right side of the bed, Certified Nursing Assistant (CNA) 2 turned Resident 2 to her right side, away from the CNA.This deficient practice resulted in Resident 2 falling out of bed and onto the floor on 1/23/26. Resident 2 sustained injuries including a fracture (broken bone) to her right elbow.2. The staff did not implement interventions timely to prevent further falls and to reduce the impact of potential falls after Resident 2's fall incident on 1/23/26.This failure exposed Resident 2 to potential falls and associated injury.Findings:1. […]

• Actual harm, isolatedF600Dec 14, 2021

  Based on observation, interview, and record review, the facility failed to provide sufficient protection to prevent abuse and/or neglect for five of eight sampled residents, when: 1. Resident 5 was assaulted by Resident 2, who was accompanied by Resident 1, on 10/24/21, and then by Resident 1 on 11/4/21, and suffered from fear and increased anxiety, 2. Resident 3 was assaulted by Resident 1 on 10/11/21, and was injured on her chest and right wrist, 3. Resident 4 was assaulted by Resident 1 on 10/12/21, and experienced emotional distress with tearfulness, 4. Resident 6 was slapped by Resident 1 on 10/24/21, with the potential to cause emotional distress, and, 5. […]

• Actual harm, isolatedF686Dec 10, 2021

  Based on observation, interview, and record review, the facility failed to implement interventions to prevent and/or heal pressure injuries (areas of damaged skin caused by staying in one position for too long) for two of four sampled residents (Resident 5, and Resident 61) when: 1. Resident 5 developed a pressure injury to his right heel, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident 61 was admitted with a pressure injury to his sacrum (tailbone) and interventions were not in place to heal the pressure injury, or to prevent new pressure injuries from forming. These failures resulted in Resident 5 developing a pressure injury to his right heel and had the potential to delay the healing of Resident 61's pressure injury to his sacrum. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF812Nov 8, 2024

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices for a total of 127 residents receiving food from the kitchen when: 1. Food items available for use in the dry storage area, were found in an opened and unsealed container and/or past their use by or best by dates; 2. Vegetables available for use in the walk-in refrigerator were wilted, decomposing, and moldy, and containers of sour cream were past their best by dates; 3. Freezer #2 contained ice buildup on all four walls; and, 4. […]

• No harm, potential for more than minimal, widespreadF812Apr 27, 2023

  Based on observation, interview, and record review, the facility failed to ensure food was prepared and served in accordance with professional standards for food safety for 134 resident who received food service from the kitchen when; 1. Food temperatures were not periodically checked during meal service (plating of food) to ensure proper holding temperatures; 2. The steam table (Used to keep food items hot for long periods of time and safe for consumption. The steam table has a large bottom well where water is heated to the point of creating steam. Then food pans are placed on top of the water well so the hot steam heats up the food pans and maintains hot temperatures until it is served.) was in a state of disrepair; and 3. […]