Eagle Crest Rapid Recovery

In the surveyor’s words

From the most serious findings on record at Eagle Crest Rapid Recovery, in the surveyor’s own words.

• Immediate jeopardy, patternF656Sep 21, 2025

  Based on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental, and mental and psychosocial needs that were identified in the comprehensive assessment for 6 of 7 residents (Residents #4, #41, #30, #1 #37 and #62) reviewed for care plans. 1. The facility failed to develop and implement a plan of care that addressed the prevention of facility acquired pressure ulcers/injury . 2. […]

• Immediate jeopardy, patternF686Sep 21, 2025

  Based on observation, interview, and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 5 of 7 (Residents #4, #41, #30, #1 and #37) residents reviewed for pressure ulcers.- The facility failed to turn and reposition Resident #4 every 2 hours and failed to identify skin issues during CNA skin monitoring during showers and nurse skin assessments. Resident #4 developed an in-house stage 4 pressure to his heel without any previously documented skin concern. […]

• Immediate jeopardy, isolatedF578Jan 28, 2026

  Based on interviews and record reviews, the facility did not ensure that the resident's requests, refusals, discontinuations, and advance directives were honored for 1 of 1 (CR#1) resident's DNR. LVN A provided CPR to CR #1 prior to determining if the resident had advanced directives in place resulting in CR #1 receiving life-saving intervention from LVN A and then emergency responders. Emergency responders did restore CR #1's pulse and CR#1 was transported to the hospital where CR#1 expired. The noncompliance was identified as Past Non-Compliance. The IJ began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. […]

• Immediate jeopardy, isolatedF689Oct 12, 2023

  Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to properly inspect the Hoyer Lift slings, resulting in it tearing and causing the resident to have a fall and sustain a bruise to her left shoulder. Resident #1's fall caused pain at a level 9. -The facility failed to properly train the staff on how to report concerns and determine properly Hoyer sling sizes. An Immediate Jeopardy (IJ) was identified on 10/09/2023 at 6:35 PM. The IJ template was provided to the facility on [DATE] at (6:35PM. […]

• Immediate jeopardy, isolatedF697Oct 12, 2023

  Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 5 residents (Resident #1) reviewed for pain management, in that; Resident #1 experienced pain after a fall on 10/06/2023 and the pain was not reported to the NP until 10/09/2023. The facility failed to contacted the NP or Physician after the fall when Resident #1's pain level increased to a level 9, resulting in an increase PRN pain medications. These failures affected one resident who was placed at risk of pain, bruising, and increased use of PRN pain medication. An Immediate Jeopardy (IJ) was identified on 10/09/2023 at 6:35 PM. […]