Health inspection·January 5, 2026

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 Page 1 of 2 366003 366003 01/05/2026 Crystal Care Center of Franklin Furnace 4734 Gallia Pike Franklin Furnace, OH 45629

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 366003 Page 2 of 2