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Inspection visit

Health inspection

The Terrace at Crystal LLCCMS #24528927 citations on this visit
27 citations recorded

Citations

27 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0921GeneralS&S Epotential for harm

    F921 - Other Environmental Conditions

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  • 0550GeneralS&S Fpotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0576GeneralS&S Fpotential for harm

    F576 - The resident has the right to have reasonable access to the use of a telephone,

    Ensure residents have reasonable access to and privacy in their use of communication methods.

  • 0867GeneralS&S Fpotential for harm

    F867 - Program feedback, data systems and monitoring

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0578SeriousS&S Jimmediate jeopardy

    F578 - The right to request, refuse, and/or discontinue treatment, to participate in or

    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0628GeneralS&S Dpotential for harm

    F628 - Documentation

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0657GeneralS&S Dpotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0677GeneralS&S Epotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0689SeriousS&S Kimmediate jeopardy

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0697GeneralS&S Dpotential for harm

    F697 - Pain Management

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0725GeneralS&S Fpotential for harm

    F725 - Nursing Services

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0726GeneralS&S Dpotential for harm

    F726 - Nursing Services

    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.

  • 0730GeneralS&S Fpotential for harm

    F730 - Regular in-service education

    Observe each nurse aide's job performance and give regular training.

  • 0740GeneralS&S Dpotential for harm

    F740 - Behavioral health services

    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

  • 0757GeneralS&S Dpotential for harm

    F757 - Unnecessary Drugs—General

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

  • 0804GeneralS&S Epotential for harm

    F804 - Food and drink

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0880SeriousS&S Kimmediate jeopardy

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0919GeneralS&S Fpotential for harm

    F919 - Resident Call System

    Make sure that a working call system is available in each resident's bathroom and bathing area.

  • 0941GeneralS&S Fpotential for harm

    F941 - Training Requirements

    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

  • 0942GeneralS&S Fpotential for harm

    F942 - Training Requirements

    Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

  • 0944GeneralS&S Fpotential for harm

    F944 - Quality assurance and performance improvement

    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

  • 0946GeneralS&S Fpotential for harm

    F946 - Compliance and ethics

    Provide training in compliance and ethics.

  • 0949GeneralS&S Fpotential for harm

    F949 - Training Requirements

    Provide behavior health training consistent with the requirements and as determined by a facility assessment.

FAQ · About this visit

Common questions about this visit

What happened during the December 8, 2025 survey of The Terrace at Crystal LLC?

This was a inspection survey of The Terrace at Crystal LLC on December 8, 2025. The surveyor cited 27 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at The Terrace at Crystal LLC on December 8, 2025?

Yes, 27 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.