Crystal Oaks

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold policy upon transfer to the hospital for two residents (Residents #7 and #79) out of five sampled residents and failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital for one resident (Resident #79) out of five sampled residents. The facility also failed to complete a discharge summary that included a recapitulation of stay, describing the resident's course of treatment while residing in the facility, for one resident (Resident #136) out of two closed records reviewed. The facility's census was 120. The facility did not provide a policy. 1. Review of Resident #7's medical record showed: - admitted on [DATE]; - Transferred to the hospital on [DATE] and returned to the facility on [DATE]; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during wound care for one resident (Resident #27) and urinary catheter (a flexible tube that is placed to drain urine from bladder) care for one resident (Resident #44) out of three sampled residents. The facility census was 120. [...]

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure food was served under sanitary conditions and failed to ensure kitchen equipment were cleaned and stored in a manner to prevent contamination from foreign substances and the potential for development of foodborne illness. Specifically, the facility did not ensure staff used and maintained proper hand hygiene during food service and distribution, as well as failing to clean and maintain ice/water machine and steam table. This deficient practice has the potential to affect 117 of 117 residents who receive meals and beverages prepared in and served from the facility's kitchen.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan that addressed activities for six of 28 sampled residents (Resident (R) 33, R59, R67, R85, R89, and R102). This failure had the potential to result in activities not provided for the residents. Facility census was 117.

Inspectors wroteBased on interview, record review, document review and facility policy review, the facility failed to provide a program of activities to support residents in their choice of activities on the weekends for six of six residents (Resident (R) 33, R59, R67, R85, R89, and R102) that attended the group meeting. This failure had the potential to negatively impact the quality of life for the affected residents. The facility census was 117.

Inspectors wroteBased on observation, interview, and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure one of one clean laundry cart was covered to prevent potential contamination of all residents' in the facility personal items. The facility census was 117.

Inspectors wroteBased on observation and interview, the facility failed to provide one of five shower rooms (300 unit shower room) that was functional and had a sanitary environment for residents in the facility. Specifically, the facility failed to ensure that the 300 unit shower room was clean and free of mold and feces on the floor, the shower curtain was free of brown stains, the shower cord did not spray water and the toilet was clean and in good repair. These failures had the potential to affect all residents on the 300 hallway who used the 300 shower room. The facility census was 117.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's sense of well-being was promoted due to enhanced barrier precautions (EBP). Specifically, a sign was posted on the door for one of 28 sampled residents (Resident (R) 30), which caused a negative effect on R30's sense of well-being. The facility census was 117.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that mail was delivered on Saturdays to the residents of the facility. This deficient practice has the potential to affect all of the residents in the facility. The failure to not receive mail on Saturday could cause residents to not receive important business documents timely and family communications. The facility census was 117.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) of three sampled residents was free from significant medication error when staff failed to verify the medication administered correlated to the physician's orders for 16 doses of a high alert (medication that bears a heightened risk of causing significant patient harm when they are used in error) chemotherapy medication (treatment that uses powerful chemicals to kill fast-growing cells in your body) which resulted in increased pain and multiple infections due to the properties of the medication and toxicity. The resident died as a result. The facility census was 118. The administrator was notified on [DATE] at 3:30 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 94. Record review of the facility's policy titled, Operational Manual, dated September 2013, showed: - It is policy that the dietary department participates in a strict environmental sanitation program; - Staff is trained to properly clean and sanitize all food service equipment in the food service department; - Steam tables, ovens, carts, racks, tables and all other equipment is cleaned and sanitized by Dietary daily; - Cracked China and glassware will be discarded; - Dishwashing procedures and techniques will be carried out as specified by State and local health codes; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage dumpster and trash receptacles were covered for four of four days of observation. The facility census was 94. 1. Observation of the kitchen on 1/24/23 at 12:50 P.M. showed one uncovered trash receptacle partially full of refuse near the hand washing facility. 2. Observation of the dumpster area on 1/25/23 at 2:31 P.M. showed one 40 yd. (yard) compactor dumpster (a machine or mechanism used to reduce the size of material or bio mass through compaction) partially filled with trash bags that were full of refuse in the opened collection area of the dumpster. 3. Observation of the dining room serving area on 1/25/23 at 3:22 P.M. showed one uncovered, brown, 13 gal. (gallon) trash receptacle partially full of refuse beside the steam table. 4. Observation of the dumpster area on 1/26/23 at 9:34 A.M. and 1:05 P.M. [...]