Crystal Ridge Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Oct 7, 2022

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. The preparation sink next to the stove (Cook prep sink) did not have an air gap (an air gap refers to a fixture that provides back-flow prevention. When installed and maintained properly, the air gap works to prevent drain water from backing up into the sink and possibly contaminating the area used for washing food. An air gap is a way to make certain wastewater and contaminants never re-enter the clean water supply), which had the potential for backflow from the drain to contaminate the sink. This had the potential to cause foodborne illness, (stomach illness acquired from ingesting contaminated food). 2. […]

• No harm, potential for more than minimal, patternF658Jul 16, 2026

  Based on observations, interviews and record review, the facility failed to ensure services provided met professional standards of quality for six (6) out of 27 sampled residents (Resident 105, Resident 23, Resident 56, Resident 47, Resident 5 and Resident 28 when:1. Foam heel pads to float (the practice of putting a pillow or pressure relieving device below the legs of a resident to prevent the heels from touching the bed) Resident 105's heels were not applied as ordered by the physician;2. Physician orders were not followed for the use of a low air loss mattress (LAL, a specialized medical support surface designed to keep patients comfortable while protecting their skin from breakdown) for Resident 23;3. […]

• No harm, potential for more than minimal, patternF759Jul 16, 2026

  Based on observation, interview, and record review, the facility failed to ensure that the medication error rates remained below 5% when three medication errors were identified out of 32 opportunities, resulting in a medication error rate of 9.38% for a census of 94. This failure resulted in Resident 60 and Resident 64 not receiving medications as ordered by their physician. Findings:1a. During a medication administration observation on 7/14/26 at 9:29 a.m. with Licensed Nurse 5 (LN 5), LN 5 administered medications for Resident 60 including a medication containing Guaifenesin (medication used to treat chest congestion) 600mg (milligrams, a unit of measurement) with Dextromethorphan (cough suppressant) 30 mg.During a review of Resident 60's physician orders, dated 7/14/26, the physician… […]

• No harm, potential for more than minimal, patternF812Jul 16, 2026

  Based on observation and interview, the facility failed to store food in accordance with professional standards of food safety for 94 residents eating facility prepared food, when several food items were not dated, and a food item was not disposed of once past the use-by date.These failures present a potential risk of foodborne illnesses for residents eating facility prepared meals.Findings:During the initial kitchen tour on 7/13/26 at 8:03 a.m., with the Kitchen Supervisor (KS) for confirmation, the following prepared or opened items were not dated in the reach-in refrigerator: one container of prepared thickened juice, one container of thickened dairy, and one container of thickened cranberry concentrate. […]

• No harm, potential for more than minimal, patternF842Jul 16, 2026

  Based on interview and record review, the facility failed to ensure medical records were accurate and consistent for three of 27 sampled residents (Resident 24, Resident 84, and Resident 90) when the residents' Controlled Drug Records (CDR - a log used to track the receipt, storage, dispensing, administration, and disposal of high-risk medications) were not reconciled accurately with the Medication Administration Records (MAR - a record that tracks medications given, including dosage, time, route, and who administer it). […]