F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
Based on observations, record review, staff interview, and facility policy review, the facility failed to ensure
each resident received food in a form to meet their individual chewing or swallowing needs. This affected
three of seven individuals who required food/drinks with altered texture (Residents #14, #15, and #17). The
facility census was 28. Findings Include:1.Review of the record for Resident #14 revealed an admission
date of 11/17/25, diagnoses including diabetes, hypertension, and chronic obstructive pulmonary disease.
A nutrition assessment by the dietician on 11/23/25 stated the resident required a diet of mechanical soft
texture with chopped meats.Review of the Minimum Data Set assessment completed 12/18/25 documented
a brief interview for mental status (BIMS) score of 13, indicating intact cognition. MDS further documented
the resident had no choking or swallowing issues. Review of physician's order on 12/05/25 indicated the
resident was to receive a mechanical soft diet with chopped meats. Observations on 12/31/25 at 12:10 P.M.
revealed Resident #14 to receive her lunch tray in her room. The card on the tray stated the meat was to be
chopped. Observations revealed a regular consistency piece of Salisbury baked steak. The meat had not
been chopped up. The resident began to try to eat the meat in regular form.Interview with the Director of
Nursing on 12/31/25 at 12:23 P.M. confirmed Resident #14's Salisbury baked steak had not been chopped
and should have been.Interview with Dietary Manager #55 on 01/05/26 at 11:00 A.M. revealed when meat
is ordered to be chopped it should be cut into pieces that are not bigger than one inch. Further interview on
01/05/26 at 11:10 A.M. the Director of Nursing stated Resident #14's meat was to be chopped as she
refuses to wear her dentures. 2. Review of the record for Resident #15 revealed an admission date of
05/05/25, diagnoses including Kufor-Rakeb Syndrome (a neurological disorder causing juvenile-onset
parkinsonism) and dysphagia (difficulty swallowing). Review of a hospital discharge summary of 05/05/25
revealed because of a modified barium swallow on 04/10/25, he was to receive honey thickened
liquids.Review of Minimum Data Set assessment on 12/16/25 documented he had a BIMS score of 11,
indicating moderately impaired cognitive status. He had a physician's order dated 05/15/25 for honey
thickened liquids. Observations on 12/31/25 at 12:12 A.M. revealed Resident #15 to receive his lunch tray in
the lounge area across from the nursing station. He was observed to receive a cup of water and a cup of
Kool-Aid. Interview with Registered Nurse #72 on 12/31/25 at 12:12 A.M. confirmed the liquids were not
thickened. She stated she thought the order for thickened liquids had been discontinued. She checked the
physician's orders and stated the liquids were to be thickened to honey consistency. She then took the
liquids and added thickener to honey consistency. Review of a speech therapy screen on 01/04/26 revealed
Resident #15 arrived to the facility with a diet requiring honey thick liquids. This indicates a significant
swallowing disorder. An assessment when he first arrived to the facility revealed no clinical signs or
symptoms of aspiration. However, he is most likely experiencing silent aspiration. It is recommended that he
have a modified barium swallow study to determine if he is safe for a diet upgrade. 3. Review of the record
for Resident #17 revealed an admission
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
366003
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366003
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/05/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care Center of Franklin Furnace
4734 Gallia Pike
Franklin Furnace, OH 45629
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
date of 12/28/25 and diagnoses including dementia and dysphagia (difficulty swallowing). A physician's
order on 12/28/25 indicated the resident was to receive a mechanical soft diet with ground meats. The plan
of care dated 01/02/26 stated the resident was at risk for swallowing problems related to no teeth. It stated
he wears only upper denture. Speech therapy notes dated 01/04/26 stated they were working on
compensatory strategies to address swallow dysfunction focused on alternating liquids/solids to increase
pharyngeal clearance, liquid delivery using small/controlled sips/intake, modification to bolus sizes and
order/method of food/liquid presentation, rate control, and small bites/sips (1/2-1/3 teaspoon). Observations
on 12/31/25 at 12:15 P.M. revealed Resident #17 to receive his lunch tray in his room. He received a regular
consistency piece of Salisbury baked steak. The meat was not ground. Interview with the Director of
Nursing on 12/31/25 at 12:25 P.M. revealed Resident #17's meat was not ground and should have been.
Interview with Dietary Manager #55 on 01/05/26 at 11:00 A.M. revealed when meat is ordered to be ground
it should be put in the food processor and ground into small pieces with gravy added after grinding. She
stated that when meat is ordered to be chopped it should be cut into pieces that are not bigger than one
inch. Review of the facility procedure revised January 2019 revealed the following diets are modified in
texture to promote ease of chewing and swallowing. No two patients/residents are alike; therefore diets
must be individualized based on their chewing/swallowing ability. Mechanical soft: this diet is used for
patients/residents with limited chewing ability. The portion units used for any ground recipes have been
updated to include the amount of sauce and/or gravy used in the recipe preparation. As a general rule,
three ounces of protein, when ground, becomes an eight ounce scoop. This deficiency represents
non-compliance investigated under Complaint Numbers 2703787.
Event ID:
Facility ID:
366003
If continuation sheet
Page 2 of 2