Crystal Care Center of Ashland

In the surveyor’s words

From the most serious findings on record at Crystal Care Center of Ashland, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 6, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interview, closed medical record review, facility policy review, review of an Emergency Medical Services (EMS) run report, and hospital records, the facility failed to ensure Resident #60 was transferred and weighed in a manner consistent with his plan of care. This resulted in Actual Harm on [DATE] at approximately 9:00 A.M. when Resident #60 was weighed while using a Hoyer (mechanical) lift by Certified Nursing Assistants (CNA) #150 and #152. Resident #60 raised himself up in his electric lift chair, stood up with the assistance of his front wheeled walker, and a Hoyer lift sling was placed underneath him. […]

• Actual harm, isolatedF684May 6, 2025

  Based on medical record review, resident interview, staff interview, Nurse Practitioner (NP) interview, review of hospital records, and review of facility policy, the facility failed to adequately monitor Resident #271's cellulitis (potentially serious bacterial skin infection), failed to timely identify a change in condition, and further failed to notify the physician of the resident's decline. This resulted in actual harm for Resident #271 on 03/29/25 when the facility failed to adequately monitor the resident's right lower extremity cellulitis to identify a worsening of the condition and, therefore, did not notify the physician of the decline. Resident #271's family member intervened and requested the facility transfer the resident to the hospital for further evaluation and treatment. […]

• No harm, potential for more than minimal, widespreadF725May 6, 2025

  Based on resident interview, staff interview, review of the Facility Assessment (FA) and review of staffing reports, the facility failed to have sufficient staff to meet resident needs as identified in the FA. This had the potential to affect all 59 residents of the facility. The facility census was 59. Findings include: Interview with Resident #30 on 04/28/25 at 9:34 A.M. revealed the facility was extremely short staffed and her call light went unanswered on multiple occasions, which resulted in her urinating on herself in bed. Resident #30 revealed call lights were often unanswered within 30 minutes on second and third shifts. Interview with Resident #35 on 04/28/25 at 10:04 A.M. revealed Certified Nursing Assistants (CNAs) took a long time to answer call lights. […]

• No harm, potential for more than minimal, widespreadF812May 6, 2025

  Based on observation, staff interview and review of the facility policy, the facility failed to maintain a clean and sanitary kitchen and further failed to ensure food items were not stored directly on the floor. This had the potential to affect all 59 residents who received meals from the facility kitchen. The facility census was 59. Findings include: Observations on 04/28/25, beginning at approximately 8:15 A.M., revealed the following: The dry storage area, located in the main kitchen, revealed there were three crates of onions stacked and stored directly on the floor. The wall behind the dishwashing machine had an unknown black substance, which went from mid-wall down to the floor. There was buildup and debris under a metal table located in the kitchen. […]

• No harm, potential for more than minimal, widespreadF880Sep 14, 2022

  Based on medical record review, observation, staff interview, review of the county positivity rate, review of the Centers for Disease Control (CDC) online resources, and policy review, the facility failed to ensure staff sanitized their eye protection upon leaving the room of residents identified to be on transmission-based precautions. This had the potential to affect all residents residing in the facility. The facility census was 57. Findings include: 1. Observation on 09/06/22 at 4:30 P.M. of the designated COVID-19 unit entrance, revealed a set of double-doors with signage instructing those entering to see the nurse prior to entering. Additional signage was posted regarding donning and doffing procedures for personal protective equipment (PPE). […]