Crystal Heights Care Center

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff provided range of motion (ROM) (joint movement exercises) to maintain functional status and prevent joint contractures (permanent tightening of muscles or joints) for 1 of 2 residents reviewed for restorative care (Resident #37). The facility reported a census of 68 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff served meals in a timely manner for 7 of 7 residents (Resident #3, Resident #55, Resident #58, Resident #64, Resident #68, Resident #38, and Resident #28) reviewed for meal service. The facility reported a census of 68 residents.

Inspectors wroteBased on clinical record review, policy review, staff, and resident interviews, the facility failed to ensure residents had access to their personal funds in a timely manner for 1 of 1 resident reviewed for personal funds (Resident #55) and for 9 of 9 additional residents who did not have access to their funds for their shopping needs. The facility reported a census of 68 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff provided planned activities and supervision for 3 of 3 residents (Resident #17, Resident #20, Resident #19) living on the Memory Care Unit. The facility reported a census of 68 residents.

Inspectors wroteBased on review of Quality Assurance and Performance Improvement(QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assurance(QA) activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 68 residents.

Inspectors wroteBased on Clinical record review and staff interview, the facility failed to follow medication administration protocol resulting in the wrong medication being administered. (Resident#1). The facility reported census was 70.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to ensure the Care Plan identified Hospice services, correct transfer status, activities, and behavioral interventions for Post-Traumatic Stress Disorder (PTSD), and lacked documentation of care conferences conducted for 7 of 19 residents reviewed for Care Plans (Residents #15, #33, #34, #37, #44, #56 #61). The facility reported a census of 62 residents.

Inspectors wroteBased on observations, representative, staff interviews, record review, and facility policy review the facility failed to provide the residents in the Chronic, Confusion, and Dementia Illness (CCDI) unit a activity program built to meet the interests of and support the physical, mental and psychosocial well-being of each resident.

Inspectors wrote3. On 6/25/25 at 8:05 AM, observation of Resident #14 revealed the resident was sitting in the dining room with Staff A, LPN (Licensed Practical Nurse), next to her. Staff A fed the resident a bite of oatmeal. Resident #14 said, That's too hot. Staff A responded that it wasn't too hot and tried to give the resident another bite. Resident #14 stated, If you burned your mouth you would think it was too hot too. Resident #14 refused to eat any more of the oatmeal. Based on observation, clinical record review, and staff interview, the facility failed to treat 2 of 5 residents reviewed for dignity with respect by failing to assist a resident to the bathroom when the need was voiced (Residents #14 and #44) and by failing to acknowledge a resident's food temperature preferences (Resident #14). The facility reported a census of 62 residents.

Inspectors wroteBased on clinical record review, policy review, and staff and resident interviews, the facility failed to ensure residents had ready access to their personal funds for 1 of 1 residents reviewed for personal funds(Resident #33). The facility reported a census of 62 residents.

Inspectors wroteBased on Code Status Form, observation, record review and interview the facility failed to ensure consistent documentation of code status for 1 of 24 resident reviewed for advanced directives (Resident #15). The facility reported a census of 72 residents.

Inspectors wroteBased on clinical record review, observation and staff interviews, the facility failed to ensure staff completed the assessment of residents to accurately reflect their status for 2 of 19 sampled residents (Resident #18 and #12). The facility reported a census of 62 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to assist 1 of 2 residents reviewed for toileting assistance to the bathroom when the need was voiced(Resident #14). The facility reported a census of 62 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to ensure 1 of 1 resident reviewed for pain received treatment and care related to pain management(Resident #14). The facility reported a census of 62 residents.

Inspectors wroteBased on clinical record review, resident/family interview and staff interview, the facility failed to ensure residents who were trauma survivors received trauma-informed care to eliminate or mitigate triggers that might have caused re-traumatization of the resident for 2 of 2 sampled residents (Resident #1 and #34) identified by either record review or interview as being a trauma survivor. The facility reported a census of 62 residents.

Inspectors wroteBased on clinical record review, policy review, resident/family interview and staff interview, the facility failed to ensure they had sufficient nursing staff to meet the needs of the residents for 3 of 19 sampled residents (Resident #1, #13, and #50). The facility reported a census of 62 residents.

Inspectors wrote2. On 6/26/25 at 11:24 AM, Staff B, Registered Nurse (RN), removed Furosemide and Tramadol from the medication cart and put the medications in a cup with applesauce. Staff B approached Resident #5 with the medications, fed the resident the medications with a bite of applesauce. Staff B then touched the resident's shoulder and returned to the medication cart. Staff B threw away the used medication cup, charted, flipped between the residents' Medication Administration Records (MARs), put applesauce in a cup, opened the medication cart with the keys, removed a medication cassette with Acetaminophen from the cart, dropped two tabs in the cup with applesauce, returned the cassette to the medication cart and locked the cart. [...]

Inspectors wrote2. The Minimum Data Set (MDS) assessment, dated 10/08/23, revealed Resident #54 diagnoses included: Congestive Heart Failure, anemia, Diabetes Mellitus, anxiety disorder, bipolar disorder, and Schizophrenia. The MDS indicated Resident #54 had disorganized thinking, trouble sleeping, and feeling down or depressed nearly every day of reference period. Resident #54 required the following types of medications: antipsychotic, insulin, and diuretic, on a daily basis. The Baseline Care Plan, dated 10/03/23 for an admission date of 10/02/23, revealed Resident #54 required 1500 milliliter (mL) per day fluid restriction and diabetic ulcer wound care upon admission. On 12/06/23 at 02:00 PM Assistant Director of Nursing (ADON), revealed she was responsible for Care Plans and stated if a Care Plan was not in a resident's Electronic Health Record (EHR), it had not been done. [...]