PruittHealth-Crystal Coast

In the surveyor’s words

From the most serious findings on record at PruittHealth-Crystal Coast, in the surveyor’s own words.

• Immediate jeopardy, isolatedF742Jun 23, 2026

  Based on record review, staff, Medical Director, and family member interviews, the facility failed to ensure Resident #1 received a mental health evaluation and monitoring, failed to implement suicide precautions and failed to heighten awareness amongst all staff after Resident #1 had disclosed suicidal ideations. On 6/8/26 at 10:00pm, Resident #1 was found in his bed with the cord to the bed control wrapped around his neck tight with no breath or pulse. Nurse #2 called a code blue (a facility wide announcement that a resident was not breathing and without a pulse) and began Cardiopulmonary Resuscitation (CPR) while Nurse Aide (NA) #1 called for emergency medical services. […]

• No harm, potential for more than minimal, patternF580Oct 3, 2024

  Based on record review, staff interviews and physician interview the facility failed to inform the physician of a change in the residents' nutritional status and failed to notify the responsible party of changes in a resident's condition including skin integrity impairment and/or weight loss for 4 of 5 residents sampled for nutrition. (Resident #4, Resident #41, Resident #45, and Resident #81) The findings included: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses including dysphagia. Review of Resident #4's weights revealed: 08/06/2024 112.1 pounds (lbs.) 09/03/2024 103.9 lbs. 09/16/2024 105.7 lbs. 09/23/2024 106 lbs. 10/01/2024 104.6 lbs. There was a decrease of 7.31% from 8/06/2024 (112.1lbs) to 9/03/2024 (103.9lbs). […]

• No harm, potential for more than minimal, patternF584Oct 3, 2024

  Based on record review, and resident, ombudsman, and staff interviews, the facility failed to allow the residents to personalize their space by restricting their ability to hang any items on the walls or doors to their rooms to include pictures and decorations and not permitting the residents to bring in their own furniture. The residents expressed feeling as though it was impossible to make their rooms homelike with these restrictions. This deficient practice affected 5 out of 5 residents (Resident #19, # 54, #50, #16 and #25) reviewed for homelike environment and had the potential to affect other facility residents. […]

• No harm, potential for more than minimal, patternF812Oct 3, 2024

  Based on observation and staff interviews, the facility failed to label opened food items, stored in their walk-in refrigerator in the kitchen, with the date opened and a use-by or expiration date. This practice had the potential to affect foods served to the residents. The findings included: On 09/29/24 at 11:45 a.m., an observation of the of the walk-in refrigerator in the kitchen was conducted with the Assistant Dietary Manager (ADM). The observation revealed the following: --bag of thawed crab cakes - no label, no date opened, no use-by or expiration date --bag of shredded cheddar cheese - with a handwritten date of 09/23/24, no use-by or expiration date --bag of cheese slices - with a handwritten date of 09/16/24, no use-by or expiration date --bag of sliced ham - with a handwritten… […]

• No harm, potential for more than minimal, patternF584Aug 15, 2024

  Based on observations, staff and resident interviews, the facility failed to keep 3 of 8 resident rooms (Rooms #204, #206 and #706) and 4 of 4 day rooms at a temperature of 71 degrees to 81 degrees Fahrenheit (F). Findings included: An observation of the thermostat in the 700 hall day room on 8/14/24 at 8:40 AM revealed the temperature to be 61 degrees F. The thermostat was set for the room to be 72 degrees F. The room felt cold. A resident in a wheelchair was in the room and she stated her hands were cold. An observation of the thermostat in the 400 hall day room on 8/14/24 at 12:54 PM revealed the temperature to be 65 degrees F and the room felt cold. The thermostat was set for the room to be 72 degrees F. […]