Crystal Care of Coal Grove

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Mar 4, 2024

  Based on closed medical record review, review of the hospital records, review of laboratory test requisitions, review of the facility's laboratory contract, staff interviews, and review of the facility policy, the facility failed to ensure timely and appropriate care and services were provided for Resident #60 following a change in condition. This resulted in Immediate Jeopardy and the potential for serious life-threatening injuries, negative health outcome and/or death on [DATE] at 10:29 A.M. when Resident #60 experienced a decline in condition. Nurse Practitioner (NP) #500 was notified of Resident #60's decline and provided new orders to obtain STAT (urgent) laboratory tests. […]

• No harm, potential for more than minimal, widespreadF557Apr 1, 2021

  Based on observation, staff interview, and resident interview the facility failed to ensure residents were treated with dignity with respect to residents provided knives on meal trays. This had the potential to affect 42 of 44 residents who resided in the facility (all residents except Resident #23 and #37) and specifically affected Residents #20, #13. Findings include: Observation on 03/23/21 at 12:16 P.M. of resident meal trays on the Sunset Hill (a secure unit) hallway revealed no knives were on the resident's trays. Interview of State tested Nursing Assistant (STNA) #301 on 03/23/21 at 12:16 P.M. revealed residents on this unit did not have knives on their trays. Observation on 03/29/21 at 12:09 P.M. […]

• No harm, potential for more than minimal, widespreadF804Apr 1, 2021

  Based on observation, resident interview, and review of resident council minutes revealed the facility failed to ensure meat served was tender. This had the potential to affect 42 of 44 residents who resided in the facility (all except Resident #23 and #37) and specifically affected Residents #2, #13 and #20. Findings include: Review of resident council minutes revealed on 06/30/20, 09/15/20, 10/20/20, and 02/26/21 residents complained about the food that included meat not being tender. Interview of Resident #2 on 03/23/21 at 11:56 A.M. revealed the meat was dry and she could not chew it. Interview of Resident #20 on 03/23/21 at 12:05 P.M. revealed the pork and chicken were dry and over cooked. On 03/29/21 a test tray was requested. At 12:37 P.M. […]

• No harm, potential for more than minimal, widespreadF812Apr 1, 2021

  Based on observation and staff interview the facility failed to ensure food was served under sanitary conditions including food on resident trays being covered when trays were distributed to residents. This had the potential to affect 42 of 44 residents who resided in the facility (all except Residents #23 and #37). Findings include: Observation of the midday meal on 03/23/21 starting at 12:00 P.M. revealed the chocolate pudding, on resident meal trays, was not covered. Staff were distributing meal trays and were observed passing by multiple resident rooms with the uncovered pudding. The pudding was not covered on any of the resident meal trays. Interview of Licensed Practical Nurse (LPN #300) on 03/23/21 at 12:57 P.M. […]

• No harm, potential for more than minimal, patternF758Oct 19, 2023

  Based on interview, record review and facility policy review the facility failed to ensure target behaviors were identified and appropriate indications for use of antipsychotic medications. This affected six residents (#16, #28, #30, #36, #38 and #43) of seven reviewed for unnecessary medications. The facility census was 41. Findings include: 1. Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses including hypertension, psychosis and major depressive disorder. […]