Latest reports, citations, and penalties from CMS data
Her physician's orders allowed oxygen through a nasal cannula, up to five liters per minute, as needed to keep her blood oxygen above 92 percent....
The facility's own policy required a copy of any proposed discharge notice to go to the ombudsman....
Federal inspectors documented the failures during a complaint inspection on January 30, 2026....
On January 27, 2026, nobody did it....
The complaint inspection found that staff failed to document enteral tube feedings in the facility's electronic medical records system....
The resident, identified as Resident #32 in inspection records, had filed an anonymous complaint saying they felt bored at the facility....
The aide, identified in federal inspection records only as NA B, admitted to striking Resident #1....
The date on the form was unclear....
The Terrace at Crystal LLC violated federal requirements for at least two residents in January 2026, according to inspection records....
The resident at the center of the incident, identified in inspection records only as R2, had cancer and a range of behaviors that staff described as variable....
The fall happened on November 27, 2025....
The mix-up went undiscovered until after she was already gone....
One resident, identified in the report as R4, told inspectors the evening before the inspection closed: "They have used paper towels to clean me....
A nurse eased him toward the floor as he fell....
The woman, identified in inspection records only as R1, is dependent on supplemental oxygen, has a tracheostomy, and cannot speak....
Federal inspectors found the tracking failures created immediate jeopardy to resident safety, the most serious violation level possible....
The aide was eventually arrested....
The complaint inspection, triggered by the fall, found that staff did not follow through on the facility's own written procedures....
Inspectors from the California Department of Public Health arrived at the facility on January 30, 2026, following a complaint....
The immediate jeopardy designation, the most serious level of harm federal inspectors can assign, meant residents were at risk of serious injury or death....