Crystal Heights Care Center

In the surveyor’s words

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

• Actual harm, isolatedF688Jul 16, 2026

  Based 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. Findings included:Resident #37's MDS assessment dated [DATE] listed diagnoses including cancer (malignant growth), age-related debility (weakness from aging), and adult failure to thrive (decline in physical and cognitive function). Resident #37's MDS documented impairment in ROM on both sides of upper and lower extremities and a Brief Interview for Mental Status (BIMS) score of 7, indicating severely impaired cognition. […]

• No harm, potential for more than minimal, patternF809Jul 16, 2026

  Based 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. Findings included:1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of heart failure (heart muscle weakness), non-Alzheimer's dementia (memory loss), and anxiety disorder (excessive worry). Resident #3's MDS listed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 7/13/26 at 1:24 PM Staff C, Dietary Aide (DA), delivered Resident #3's lunch to her in her room. 2. […]

• No harm, potential for more than minimal, patternF657Jun 26, 2025

  Based 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. Findings include: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 4/23/25, listed diagnoses for Resident #33 which included diabetes, non-Alzheimer's dementia, and anxiety disorder. The MDS listed the resident's Brief interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. […]

• No harm, potential for more than minimal, patternF679Jun 26, 2025

  Based 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. Findings include: 1. A Quarterly Minimum Data Set, dated [DATE] for Resident #15 documented diagnosis, non-Alzheimer's dementia and coded wore a wander/elopement alarm. The Brief Interview for Mental Status (BIMS) assessment coded 00 to reflect resident, was not able to take assessment. […]

• No harm, potential for more than minimal, patternF638Jul 28, 2022

  Based on clinical record review and staff interview, the facility failed to complete quarterly review assessments once every three months between comprehensive assessments for 5 of 5 residents reviewed for the timeliness of MDS completion (Residents #3, #4, #15, #18, #20). The facility reported a census of 54 residents. Findings: 1. Review of the Minimum Data Set (MDS) history present in Resident #18's electronic health record revealed the resident's Quarterly MDS dated [DATE] remained in progress. On 7/27/22, review of the Quarterly MDS assessment dated [DATE] revealed the facility only completed Section K. All other sections of the assessment remained in progress. 2. […]