Deficiency Records for Crystal Health and Rehab Center, LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Crystal Health and Rehab Center, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-30 | 2022-08-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-30 | 2022-08-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-30 | 2022-08-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-30 | 2022-08-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-06-30 | 2022-08-01 | N |
| Provide activities to meet all resident's needs. | Health | 2022-06-30 | 2022-08-01 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-06-30 | 2022-08-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-30 | 2022-08-01 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-06-30 | 2022-08-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-30 | 2022-08-01 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-06-30 | 2022-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-30 | 2022-08-01 | N |
| Dispose of garbage and refuse properly. | Health | 2022-06-30 | 2022-08-01 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-06-30 | 2022-08-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-07 | 2022-08-01 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-07 | 2022-08-01 | Y |
| Install proper backup exit lighting. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-04-07 | 2022-05-05 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-04-07 | 2022-05-05 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-09-15 | 2021-10-15 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2020-11-20 | 2020-12-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-11-20 | 2020-12-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-11-20 | 2020-12-19 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2020-11-20 | 2020-12-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-11-20 | 2020-12-19 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-11-20 | 2020-12-19 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-11-20 | 2020-12-19 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-11-20 | 2020-12-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-11-20 | 2020-12-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-11-20 | 2020-12-19 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2020-11-20 | 2020-12-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-11-20 | 2020-12-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-11-20 | 2020-12-19 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-11-19 | 2020-12-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-11-19 | 2020-12-19 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-11-19 | 2020-12-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-11-19 | 2020-12-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-11-19 | 2020-12-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-11-19 | 2020-12-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-11-19 | 2020-12-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-11-19 | 2020-12-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-11-19 | 2020-12-19 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2020-11-19 | 2020-12-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-08 | 2019-06-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-05-08 | 2019-06-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-05-08 | 2019-06-08 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-05-08 | 2019-06-08 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-05-08 | 2019-06-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-08 | 2019-06-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-05-08 | 2019-06-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-10 | 2019-06-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-10 | 2019-06-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-10 | 2019-06-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-10 | 2019-06-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-10 | 2019-06-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-10 | 2019-06-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-10 | 2019-06-08 | N |
