Crystal Care Center of Franklin Furnace

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Jan 6, 2021

  Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, Department of Health and Human Services, Center for Medicare and Medicaid (CMS) Memos, Nursing Home Guidance from the Centers for Disease Control (CDC), observation, record review, review of facility policies including the COVID-19 Infection Control and Prevention policy and guidelines, the COVID-19 Prevention and Management policy, the Donning and Removing of Personal Protective Equipment (PPE) policy, Isolation Precautions policy, Infection Control Measures during Infectious Disease Threat policy and interviews with staff the facility failed to implement effective and recommended infection control practices to prevent the spread of COVID-19 in the… […]

• Actual harm, isolatedF689May 13, 2021

  Based on observation, record review, facility fall investigation review, review of hospital records and interview the facility failed to ensure adequate assistance and/or fall safety interventions were provided to prevent falls for Resident #16 and Resident #76. Actual Harm occurred on 10/01/20 when Resident #16, who required two staff assistance for activities of daily living including transfers and toilet use sustained a fall with injury while being assisted by one State tested Nursing Assistant (STNA) to the bed side commode. The resident was assessed to have a laceration to her face, over her left eye measuring 4.5 centimeters long by 0.2 centimeters wide which required seven sutures. This affected two residents (#16 and #76) of two residents reviewed for falls. Findings Include: 1. […]

• Actual harm, isolatedF697May 13, 2021

  Based on record review, review of hospital records, review of a fall investigation, facility policy review and interview the facility failed to provide timely effective pain management for Resident #16 following a fall on 08/22/20 at 12:28 P.M. that resulted in a dislocation of the resident's right shoulder. Actual Harm occurred when the resident was not provided effective pain relief until being transferred to the hospital on 08/22/20 at 9:47 P.M. (over nine hours after the fall occurred) at which time the resident complained of sharp constant pain rated a 10 on a scale of one to 10 with 10 being the worst pain. This affected one resident (#16) of two residents reviewed for pain management. […]

• No harm, potential for more than minimal, widespreadF812May 13, 2021

  Based on observation, staff interview and facility policy review the facility failed to properly store and date opened food items, take food temperatures without committing cross-contamination and prepare and serve meals in a sanitary manner. The had the potential to affect all 26 residents residing in the facility. Findings Include: 1. On 05/03/21 from 12:10 P.M. to 1:21 P.M. an initial tour of the kitchen revealed a large container of Lite Buttermilk Ranch dressing, dated 04/01/21 and a large container of Creamy Coleslaw dated 02/11/21 were observed in the refrigerator. Both of the containers had been opened and some of the contents were missing at the time of the observations. On 05/03/21 at 12:55 P.M. […]

• No harm, potential for more than minimal, widespreadF880Feb 18, 2021

  Based on observation, interview, record review, and in-service documentation review, the facility failed to ensure visitors were screened upon entry to the facility. This had the potential to affect all 22 residents residing at the facility and specifically affected Resident #7. Findings Include: 1. On 02/09/21 at 10:28 A.M. State tested Nursing Assistant (STNA) #122 opened the door for the surveyor to enter the facility. The STNA proceeded to the activity/kitchen area to return a resident tray. STNA #122 returned to the entry area and received a delivery and then asked surveyor if she needed the nurse. On 02/09/21 at 10:31 A.M. the Director of Nurses (DON) was informed the surveyor had not been screened for signs and symptoms of COVID-19 upon entry and the DON screened the surveyor. […]