The scene at Crystal Cove Post Acute repeated itself across multiple days in late January, according to federal inspection records. Inspectors documented residents sitting or lying in darkness for hours at a time, despite individualized activity plans that called for music, television, one-on-one visits, and other forms of stimulation.
The facility's activities assistant had quit two weeks before the inspection, and the activities director was out sick. "We had not had activities for the past week," Social Services Director Staff DD told inspectors on January 29.
Resident 69, who does not speak English but understands some, had a care plan documenting she "enjoys music, watching TV, one on one visits from staff and being outdoors." An activities assessment from November showed she liked Christian and Marshallese music, bingo, and painting.
But electronic health records showed minimal activity provision. Resident 69 listened to music on just two days in January. She watched TV on seven days. She had one-on-one visits on only three days during the entire month.
On January 27, inspectors watched from 8:39 AM until 10:54 AM as Resident 69 remained in bed in darkness. Fifteen staff members entered her room during those two hours and 15 minutes. None offered activities.
The pattern continued the next day. From 9:01 AM to 11:22 AM, Resident 69 sat in her wheelchair in the dark. Twenty staff members entered the room. Again, nobody offered activities, music, or television.
Activities Director Staff VV acknowledged the failures when confronted with the observations. "That was not accepted and staff should have offered/provided Resident 69 with individual activities," she said.
The facility's activity neglect extended beyond language barriers. Resident 61, who was cognitively intact, had expressed that listening to music was "very important" to them. Getting fresh air and keeping up with news were "somewhat important."
Yet inspectors found Resident 61 lying in bed repeatedly without television or music on January 22, 23, 27, and February 3 and 5. The resident's care plan called for one-on-one visits with staff two to three times per week, but records showed only one such visit in all of January.
When asked why activity staff hadn't provided the planned visits, Activities Director Staff VV said the resident "preferred to direct her own activities" but acknowledged staff should have attempted interaction according to the care plan.
The most troubling case involved Resident 27, who had severe cognitive impairment and was receiving hospice care. This resident had specifically indicated that having books, newspapers, magazines, and music was "very important." Group activities, favorite activities, fresh air, and religious services were "somewhat important."
Resident 27's care plan included an extensive list: one-on-one visits, exercise, family visits, reading activities, radio and television, sensory stimulation, and "sunshine therapy." Staff were supposed to encourage group activities and provide reading materials and two one-on-one visits weekly.
Instead, inspectors found Resident 27 repeatedly lying in bed with eyes closed, no activities visible, and no television on their side of the room. On February 3, the resident was observed staring at their roommate's television, which had the sound turned off because the roommate was on the phone.
When asked what activities Resident 27 enjoyed, staff gave conflicting answers. CNA Staff KK said they liked watching TV, resident activities, and showering. Licensed Practical Nurse Staff EE was "unsure" but guessed bingo.
Activities Director Staff VV said Resident 27 liked TV but claimed they preferred watching their roommate's television. When asked what happened when the privacy curtain was pulled, blocking the view, Staff VV said, "I see the issue."
Director of Nursing Staff B was more direct when told about Resident 27 not having access to television: "Yes, Resident 27 definitely should have their own entertainment."
The activity failures occurred alongside other care breakdowns. Three residents went days without receiving prescribed bowel medications despite having no bowel movements for four to six days. The facility's own protocol called for intervention after 72 hours.
Resident 32 went six days without a bowel movement in January, from the 8th through the 14th. No medications were given, and no physician was notified. The resident told inspectors that sometimes "it was very hard to go" and there had been times when they couldn't have a bowel movement for several days.
Director of Nursing Staff B acknowledged the protocol failures. "There should have been pharmacological and non-pharmacological interventions implemented by day three of no BM," she said.
Similar medication lapses affected Residents 65 and 3, who went four and six days respectively without bowel movements while prescribed medications remained unused.
The facility also failed to provide basic foot care. Resident 61's toenails were observed to be "long, yellow, thick and untrimmed" with several beginning to curve around the toes. Despite weekly nail care orders, records showed "Not provided" or blank entries for every scheduled session from December through January.
The resident told inspectors that staff had never offered toenail care since admission, despite having seen a podiatrist before hospitalization. A podiatrist had visited the facility twice since the resident's admission but Resident 61 was never referred or seen.
Restorative nursing programs suffered from severe understaffing. The facility had 35 residents requiring approximately 16 hours of restorative services daily, but only one aide working 7.5-hour shifts to provide them. The restorative nurse had recently left and wasn't replaced.
"This provided Staff M with 7.5 hours to complete approximately 16 hours RNPs per day, which they acknowledged was not possible," inspectors noted.
Fall prevention measures also broke down. Resident 27, who had severe dementia and a history of falls including a broken nose in October, repeatedly had their call light placed out of reach and fall mat positioned incorrectly or folded away from the bed.
On multiple observations, inspectors found the call light draped over the headboard, behind the mattress, or dangling from the bed while the resident couldn't reach it. When asked where their call light was, Resident 27 replied, "No."
The cascade of care failures painted a picture of a facility struggling with basic resident needs. Administrator Staff A said she was trying to hire a restorative aide, while acknowledging that residents weren't receiving therapy at required frequencies.
For Resident 69, lying in darkness while staff walked past, the failures meant isolation despite a care plan specifically designed to address her communication barriers and cultural preferences. Her assessment had noted that activities should be modified for her communication deficit, and that she enjoyed independent activities.
Instead, she spent hours each day without the music, television, or human interaction that her care plan promised.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crystal Cove Post Acute from 2025-02-06 including all violations, facility responses, and corrective action plans.