Crystal Oaks

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Mar 21, 2024

  Based 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]. […]

• No harm, potential for more than minimal, widespreadF812Aug 22, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Jan 27, 2023

  Based 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 [DATE], 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… […]

• No harm, potential for more than minimal, widespreadF814Jan 27, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF656Aug 22, 2024

  Based 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. Findings include: 1. Review of R33's undated Admission Record located in the electronic medical record (EMR) in the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of Parkinson's Disease without dyskinesia. […]