Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, facility policy and procedure review and interview the facility failed provide
necessary care and services, including dressing changes and antibiotic administration for Resident #41
who had three Stage IV pressure ulcers to promote wound healing. This affected one resident (#41) of two
residents reviewed for pressure ulcers.
Residents Affected - Few
Findings Include:
Review of Resident #41's medical record revealed the resident had medical diagnoses including multiple
sclerosis (MS), major depressive disorder, panic disorder, quadriplegia, Type II diabetes mellitus without
complications, pressure ulcer of unspecified site (Stage IV), and generalized anxiety disorder.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/12/21 revealed the resident
had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. The assessment revealed
the resident had three Stage IV pressure ulcers that were present at the time of admission. Interventions
listed included pressure reducing devices for her chair and bed, turning/repositioning program, nutrition or
hydration interventions to manage skin problems, pressure ulcer care, application of nonsurgical dressings,
and application of ointments/medications other than to feet. The assessment revealed the resident received
intravenous (IV) medications within the last 14 days.
Review of the care plan for Resident #41 (initiated 09/27/19) and revised on 11/24/21 revealed the resident
had an alteration in skin integrity with pressure ulcers to left gluteal fold, right gluteal fold and coccyx
present on admission. Interventions included physical therapy screen as needed for wheelchair mobility,
resident to wear brief to contain drainage that leaks from dressing over wounds, specialty mattress to bed
as ordered, assess for pain prior to treatment and medicate per physician's orders, consult with dietitian as
needed, consults with infectious disease as needed, educate resident and family on importance of turning
and repositioning while in bed and wheelchair, encourage fluids as tolerated, encourage resident to comply
with dressing changes and explain risks/benefits, encourage resident to turn and reposition frequently,
treatment per physician orders, donut cushion to wheelchair for pressure ulcer prevention, encourage
resident to limit time in wheelchair as much as possible and offload heels while in bed.
Review of the physician's orders for November 2021 revealed Resident #41 had an order for Cefepime
Hydrochloride (HCl) Solution (an antibiotic) two grams/100 milliliters with instructions to give two grams
intravenously (IV) every 12 hours for wounds until 12/17/21. The order had a start date of 11/23/21. The
resident also had an order for Dakins (1/4 strength) Solution 0.125% (Sodium Hypochlorite) with
instructions to apply to each of the three Stage IV pressure ulcer areas on the coccyx, right gluteal fold, and
left gluteal fold two times daily, clean wound, pat dry, and pack wounds with
(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 16
Event ID:
366202
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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 0686
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Dakins soaked gauze and cover with a clean dry dressing. The dressing orders had a start date of
07/13/21.
a. Review of the Medication Administration Record (MAR) for November 2021 revealed the antibiotic,
Cefepime HCl, was scheduled to be administered to Resident #41 at 9:00 A.M. and 9:00 P.M. with a start
date of 11/23/21. The night dose on 11/23/21 was coded as other-see nurse notes. On 11/24/21, the
morning dose was marked refused and the night dose was marked as administered. Both doses on
11/25/21 were marked as administered. Both doses on 11/26/21 and 11/27/21 were coded other-see nurse
notes. Both doses were administered on 11/28/21 and 11/29/21. The morning dose on 11/30/21 was
administered and the night dose were marked as refused.
Review of the electronic Medication Administration Record (eMAR) notes, from 11/23/21 to current,
revealed on 11/23/21 at 8:58 P.M., 11/26/21 at 11:42 A.M. and 9:02 P.M., and 11/27/21 at 9:41 A.M.,
Cefepime HCl Solution was not available. On 11/28/21 at 1:01 A.M., Cefepime HCl solution medication was
not available. The pharmacy was contacted to send immediately (STAT). On 11/28/21 at 2:13 A.M., a staff
person spoke to the pharmacy. The pharmacy stated they did not have an order for the medication. The
order was faxed to the pharmacy at 1:00 A.M. on 11/28/21 and medication was to be sent immediately to
the facility.
Review of the nurse's notes revealed on 11/16/21 at 8:36 P.M. the resident had an appointment with wound
care (scheduled for) 11/22/21. There were no additional notes related to the Cefepime HCl Solution
medication, communication with the pharmacy, or communication with the physician related to the
medication not being available, administered or delivered to the facility.
Review of the pharmacy delivery statement, dated 11/28/21 confirmed Cefepime HCl two gram vial was
delivered at 12:50 A.M.
On 11/29/21 at 3:33 P.M. interview with Resident #41 revealed the resident was supposed to receive
Cefepime antibiotic twice daily to help heal an infection in her wound. The resident stated staff were
marking it like it was being given but it wasn't even in the facility. The resident stated she received the first
does of the medication on 11/28/21.
On 12/02/21 at 1:45 P.M. interview with Assistant Director of Nursing (ADON) #250 confirmed Resident #41
did have an order to start Cefepime antibiotic on 11/23/21. The nurse stated she faxed the order to the
pharmacy but the pharmacy stated they did not receive the order. The nurse stated she called the
pharmacy each night, requesting the antibiotic order but confirmed there was no documentation of the
follow up in the medical record. The order was received by the pharmacy on 11/27/21 and the antibiotic was
received at the facility on 11/28/21. The ADON confirmed any doses prior to 11/28/21 that were marked as
refused or administered on the MAR must have been done in error because that medication was not in the
facility until 11/28/21.
Review of the facility policy titled Wound Care, revised 12/2020 revealed it was the policy of this facility to
provide therapeutic treatment to heal wounds. Document the assessments, care and treatments
administered.
b. Review of the Treatment Administration Record (TAR) for November 2021 revealed there were no
dressing changes completed for any of the three wounds on 11/15/21, 11/20/21, 11/21/21, 11/25/21,
11/27/21 or 11/30/21. The dressings were changed once a day on 11/09/21, 11/12/21, 11/13/21, 11/14/21,
11/16/21, 11/17/21, 11/22/21, 11/23/21, 11/26/21, 11/28/21, and 11/29/21. There were not any refusals
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 2 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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 0686
indicated.
Level of Harm - Minimal harm
or potential for actual harm
Review of the nursing progress notes, from 11/01/21 through 11/29/21 revealed there were no notes related
to Resident #41's dressing changes not being completed.
Residents Affected - Few
On 11/29/21 at 3:33 P.M. interview with Resident #41 revealed she was supposed to have wound dressings
changed on three separate pressure ulcer areas twice a day but they were often only changed once a day
or not changed at all.
On 12/02/21 at 12:50 P.M. interview with the Director of Nursing (DON) confirmed Resident #41's dressing
changes were not marked as completed on the resident's MAR or the Treatment Administration Record
(TAR) as noted above. At the time of the interview, the DON revealed she believed it was a documentation
issue, not a care issue. And indicated the nurse forgets to go to that TAR.
Review of the facility policy titled Wound Care, revised 12/2020 revealed it was the policy of this facility to
provide therapeutic treatment to heal wounds. Document the assessments, care and treatments
administered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 3 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observation, record review and interview the facility failed to ensure fall interventions were in
place as care planned for Resident #16 who had a history of falls and was assessed to be at risk for falls.
This affected one resident (#16) of one resident reviewed for falls.
Findings Include:
Review of the medical record for Resident #16 revealed an admission date of 04/17/21 with medical
diagnoses including unspecified dementia with behavioral disturbance, generalized anxiety disorder,
abnormalities of gait and mobility, muscle weakness and Alzheimer's Disease.
Review of the plan of care, dated 04/19/21 revealed Resident #16 was at risk for falls. Interventions
included bed in lowest position except when providing direct care.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/04/21 revealed the resident
had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of three. The
assessment revealed the resident required limited assistance from one staff with bed mobility, ambulation
and transfers. The assessment revealed the resident had not had any falls at the time of the assessment.
Review of the nurse's notes from 08/01/21 through current revealed the resident experienced falls on
08/15/21, 11/01/21 and 11/09/21.
On 12/01/21 at 10:33 A.M. and 3:15 P.M. observation of Resident #16 revealed the resident was laying in
bed in her room. The bed was not in the lowest position and the resident was not receiving any direct care
at the times of the observations.
Observation and interview on 12/01/21 at 3:21 P.M. with State Tested Nursing Assistant (STNA) #266
confirmed Resident #16's bed was not in the lowest position. The STNA used the bed remote control to
lower the resident's bed at the time of the observation/interview.
Review of the facility policy titled Falls Policy, revised 10/2018 revealed it was the policy of this facility to
complete a review of resident fall risk and implementation of interventions to attempt to prevent or reduce
falls/accidents and injuries related to falls. Furthermore, current interventions would be reviewed, and a new
intervention implemented to reduce the risk of a fall.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 4 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview the facility failed to ensure Resident #1, who was identified as having had
a significant weight loss, had documented evidence of substitutes being offered when the resident ate less
than 50% of her meal as per her plan of care. This affected one resident (#1) of four residents reviewed for
nutrition.
Residents Affected - Few
Findings Include:
A review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses including Alzheimer's disease, schizophrenia, schizo-affective disorder, unspecified psychosis,
major depressive disorder and a malignant carcinoid tumor of the bronchus and lung.
A review of Resident #1's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/09/21 revealed the
resident did not have any communication issues and was cognitively intact. No behaviors or rejection of
care was noted. The resident required supervision with set up help for eating. Her height was 68 inches and
her weight was 209 pounds. She was noted to have had a significant weight loss while not on a physician
prescribed weight loss program.
A review of Resident #1's care plans revealed she had a care plan in place for an alteration in nutrition
related to multiple chronic health issues and weight changes. Interventions included offering the resident a
substitution if she ate 50% or less of her meal.
A review of Resident #1's nutrition assessment dated [DATE] for a quarterly review revealed the resident's
meal intakes were between 25 and 50%. The assessment confirmed she was known to have a loss of 5%
or more in the past month or a 10% or more loss in the last 6 months. The resident was reported to have
had a 12% or 30 pound loss in six months.
A review of Resident #1's current meal intakes on a tracking form revealed the resident was known to eat
50% or less 79 out of 90 meals that were provided. The meal tracking form did not provide any documented
evidence of Resident #1 being offered a substitute when she ate 50% or less of her meal. The meal intake
tracking form included a space for the staff to document substitutes when offered and the percentage of the
substitute taken. The staff were recording fluid amounts in that space instead of documenting a substitute
being offered or the percentage taken.
On 12/01/21 at 8:21 A.M., an interview with State Tested Nursing Assistant (STNA) #262 revealed Resident
#1 typically did not eat much for breakfast but did better with lunch and supper. She stated staff were
supposed to offer a substitute if the resident ate 50% or less of her meal. She acknowledged the resident's
meal intake tracking form had a place to document when substitutes had been offered when the resident
ate 50% or less. Staff were to indicate the number offered and percentage taken. She verified the resident's
meal intake tracking form was being marked incorrectly as it had fluid amounts recorded in the space
where they should be recording the percentage of a substitute that was consumed by the resident. She
acknowledged there were multiple days where the resident was noted to eat 50% or less with no
documented evidence of a substitute being offered.
On 12/01/21 at 2:10 P.M., an interview with the Director of Nursing (DON) confirmed Resident #1 had a
significant weight loss over the past six months and was not on a physician prescribed weight loss program.
The DON was asked about the meal intake tracking form including fluid amounts where the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 5 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
staff should have been documenting substitutes being offered and the percentage of that substitute that
had been accepted. She initially thought the numbers added were the milliliters (mls) of a supplement that
had been given as a substitute, but when verifying the amounts entered (as high as 720 ml) she agreed it
appeared to be the amount of fluids consumed during the meals. She stated if it was a supplement amount
taken it would be either 120 mls or 240 mls. The DON acknowledged, in order for the facility to show
adequate monitoring of Resident #1's nutritional status, they should have documented evidence of the
percentage of any substitutes that may have been offered when the resident ate 50% or less of her meal.
She also acknowledged that documentation was needed to show staff were offering substitutes to help
maintain her nutrition when she ate 50% or less of her meal served.
Event ID:
Facility ID:
366202
If continuation sheet
Page 6 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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 0732
Post nurse staffing information every day.
Level of Harm - Potential for
minimal harm
Based on record review and interview the facility failed to ensure the daily staffing posted information
included hours worked for Registered Nurses (RN), Licensed Practical Nurses (LPN) and State Tested
Nursing Assistants (STNA) and the number of RNs working. In addition, the staffing information sheets
contained extraneous information that made the posting unclear and hard to understand. This had the
potential to affect all 43 residents residing in the facility.
Residents Affected - Many
Findings Include:
Review of the Direct Care Staffing Sheets revealed from 11/16/21 to 11/30/21 there were 12 times when
the number of Registered Nurses working only had a checkmark placed in the staffing column area instead
of the actual number. The Direct Care Staffing Sheets did not show the actual number of hours worked for
RNs, LPNs or STNAs for each date reviewed. The Direct Care Staffing Sheet also had eight employees
names who were not RNs, LPNs or STNAs written on the bottom of the postings as providing direct and
indirect care to all residents.
On 12/02/21 at 12:43 P.M. interview with the Director of Nursing (DON) verified the RN section was not
labeled with the number of staff and the facility did not list the actual hours worked for RNs, LPNs or STNAs
daily. The DON also verified eight employees names were listed on the bottom of the sheet that were not
RNs, LPNs or STNAs.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 7 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, review of pharmacy re-order slips, facility policy review and staff interview the
facility failed to ensure medications were available from the contracted pharmacy to be administered to
residents as ordered by the physician. This affected two residents (#30 and #31) of two residents reviewed
for medication administration.
Findings Include:
1. A review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE]
with diagnoses including bipolar disorder and generalized anxiety disorder.
A review of Resident #30's physician's orders revealed the resident was to receive Citalopram
Hydrobromide (Celexa) 10 milligrams (mg) by mouth (po) every morning for bipolar disorder. The resident
was also to receive Hydroxyzine Pamoate (Vistaril) 25 mg po twice daily for generalized anxiety disorder
and Magnesium Oxide 250 mg by mouth every morning as a supplement.
On 11/30/21 at 8:42 A.M., a medication administration observation was completed for Resident #30 for the
morning medications. Medications were observed being administered by Licensed Practical Nurse (LPN)
#293. At the time of the observation, Resident #30 was not given Citalopram Hydrobromide 10 mg,
Hydroxyzine Pamoate 25 mg or Magnesium Oxide as ordered by the physician.
Observation revealed the facility medication administration cart included Magnesium Oxide 400 mg in a
stock bottle but did contain Magnesium Oxide 250 mg available in a stock bottle to be able to give as
ordered. Citalopram Hydrobromide and Hydroxyzine Pamoate would have come in their own blister card for
the resident provided by the facility contracted pharmacy.
A review of Resident #30's nurses' progress notes revealed LPN #293 documented an order had been
received to hold the Citalopram Hydrobromide 10 mg, Hydroxyzine Pamoate 25 mg and Magnesium Oxide
250 mg. The medications were to be held until they were available for administration.
On 11/30/21 at 9:13 A.M., interview with LPN #293 confirmed she did not have Citalopram Hydrobromide
10 mg, Hydroxyzine Pamoate 25 mg or Magnesium Oxide 250 mg to be able to give to Resident #30 as
ordered when she administered the morning medications on 11/30/21. She stated the Citalopram
Hydrobromide and the Hydroxyzine Pamoate were not available to be given and they only had Magnesium
Oxide 400 mg tablets available and not the 250 mg Resident #30 was ordered to receive. She contacted
the facility's nurse practitioner and received an order to hold those medications until they were available
from the pharmacy. The LPN did not provide any additional information as to why they had not been
received timely from the pharmacy.
2. A review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE]
with diagnoses including bipolar disorder with psychotic features, schizo-affective disorder, paranoid
schizophrenia and adult onset diabetes mellitus.
A review of Resident #31's physician's orders revealed the resident had orders to receive Glipizide
Extended Release (ER), an oral hypoglycemic used to lower blood sugar levels, 10 mg two tablets (20 mg)
po once daily for diabetes mellitus. The resident also had an order to receive Olanzapine
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 8 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
(Zyprexa) 2.5 mg po every morning for psychosis and Lantus 60 units subcutaneously (SQ) twice a day for
diabetes mellitus.
On 11/30/21 at 8:42 A.M., a medication administration observation for Resident #31 revealed her morning
medications were administered by Registered Nurse (RN) #276. Among the medications given to Resident
#31, Lantus 60 units SQ was not one of the medications the resident received. The nurse acknowledged
she was not giving Resident #31 her Lantus as ordered explaining that it was not available in order for her
to be able to give it. She was informed Resident #31's physician's orders would be checked and if there was
any questions as to what was or wasn't given a follow up interview would be completed.
A reconciliation of the medications Resident #31 was observed to be given on 11/30/21 at 8:42 A.M. was
completed and checked against the physician's orders and medication administration record (MARs) to
ensure she received all the medications that were ordered for her. It was noted Resident #31 should have
also received Glipizide ER 20 mg po as ordered daily and Olanzapine 2.5 mg po as ordered every morning.
Neither of the two medications were administered with the resident's other morning medications. The MAR
for November 2021 was marked with a 9 in the box where RN #276 was supposed to document her initials
showing the Glipizide, Olanzapine and Lantus had been given. The legend on the MAR indicated a 9
referenced other/ see nurses notes.
A review of Resident #31's nurses' progress notes revealed RN #276 documented in a nurse's progress
note the resident was not given her Lantus, Olanzapine or Glipizide ER as ordered on 11/30/21. The
nurse's progress note indicated the three medications were not available to be given. Prior nurses' progress
notes revealed the Olanzapine and Glipizide were also not available for administration on 11/27/21 or again
on 11/28/21.
A review of Resident #31's pharmacy re-order sheets revealed the resident's Olanzapine was last ordered
for a refill on 10/25/21. Her Lantus was last ordered for a refill on 11/11/21 and her Glipizide ER was last
ordered for a refill on 11/26/21.
On 11/30/21 at 9:48 A.M., an interview with RN #276 confirmed Resident #31 did not receive her
scheduled doses of Lantus, Glipizide and Olanzapine on 11/30/21 at 8:42 A.M. due to the medications not
being refilled timely by their contracted pharmacy company. She reported the Glipizide and the Olanzapine
had not been available for over a week now as she had contacted the pharmacy herself about needing
those medications refilled. She stated the pharmacy had told her they were on the truck but they were not
received when the delivery was made. She reported the facility had been having issues with their
contracted pharmacy sending medications when needed. As a result, the facility was planning on switching
pharmacies at the beginning of next year.
On 11/30/21 at 11:15 A.M., interview with the Director of Nursing (DON) confirmed the facility was having
problems with the pharmacy they contracted with to provide pharmacy services to the residents. She
confirmed they were planning on switching pharmacies after the first of the year. She reported Lantus was
available in the facility contingency medication supply from their emergency box in the refrigerator but
denied they had Glipizide on hand at the dose ordered for Resident #31 or the Olanzapine.
A review of the facility policy on Medication Orders and Receipt Record, revised April 2007 revealed the
facility should document all medications that were ordered and received. The DON would designate
individuals to be responsible for completing medication order/ receipt forms. Medications should
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 9 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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 0755
be ordered in advance, based on the dispensing pharmacy's required lead time.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 10 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
3. Record review of Resident #24 revealed an admission date of 10/14/21 with diagnoses including sepsis,
muscle weakness, cerebral infarction, epilepsy, anxiety disorder, hypertensive heart disease with heart
failure, gastrointestinal mucositis, type two diabetes mellitus, multiple sclerosis, heart failure, atrial
fibrillation, asthma, schizophrenia, blindness left eye, pain and depression.
Review of the 10/26/21 admission Minimum Data Set (MDS) 3.0 assessment revealed the Resident was
cognitively intact and required limited assistance for all activities of daily living and supervision for personal
hygiene, bathing and eating.
Review of the 11/10/21 pharmacy recommendation revealed Resident #24 had an order for Advair (an
inhaler). The recommendation revealed to please add instructions to rinse mouth and spit after use. The
nurse practitioner approved the recommendation and signed it 11/19/21.
Review of the Resident #24's medical record revealed the recommendation to rinse mouth and spit after
Advair use had not been implemented as of 12/01/21.
On 12/01/21 at 11:13 A.M. interview with the Director of Nursing (DON) on 12/01/21 at 11:13 A.M. verified
the Advair rinse mouth and spit recommendation was not implemented as per the nurse practitioner order.
There was another recommendation for an Abnormal Involuntary Movement Scale from the same dates
that had been completed.
Based on record review, review of pharmacy recommendations, facility policy and procedure review and
staff interview the facility failed to implement pharmacy recommendations timely for Resident #3, Resident
#23 and Resident #24. This affected three residents (#3, #23 and #24) of five residents reviewed for
unnecessary medication use.
Findings Include:
1. Review of the medical record for Resident #3 revealed the resident had medical diagnoses including
Alzheimer's Disease, Wernicke's encephalopathy, pseudobulbar affect, dementia in other diseases
classified elsewhere with behavioral disturbance, anxiety disorder, altered mental status, major depressive
disorder, unspecified mood (affective) disorder and alcohol abuse with alcohol-induced psychotic disorder
with hallucinations.
Review of the plan of care, dated 11/04/17 for Resident #3 revealed the resident was at risk for adverse
reactions related to dementia with behaviors and at risk for adverse effects related to anxiolytic drug use
related to the diagnoses of anxiety and mood disorder. Interventions included pharmacy reviews per facility
policy and Gradual Dose Reductions (GDR) per facility policy and administer medications as ordered.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/24/21 revealed Resident #3
was rarely or never understood. Per staff assessment, Resident #3 had severely impaired cognition.
Resident #3 exhibited wandering behavior daily. No other behaviors were noted. Resident #3 required
extensive assistance from one to two staff to complete Activities of Daily Living (ADLs).
Review of current physician's orders for Resident #3 revealed the resident had an order dated
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 11 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
08/18/21 for Depakote Sprinkles Capsule Delayed Release Sprinkle 125 milligrams (mg) with instructions
to give one capsule orally two times daily for behaviors. The resident also had an order for Depakote Tablet
Delayed Release 250 mg with instructions to give one capsule orally at bedtime for behaviors also dated
08/18/21.
Review of the pharmacy recommendation, dated 11/10/21 noted Resident #3 had orders for Depakote
Delayed Release tablet 250 mg at bedtime and also took Depakote Sprinkles 125 mg twice a day in the
morning and midday. The pharmacist recommended to change the Depakote Delayed Release tablet to
Sprinkles at 250 mg at bedtime if medications were crushed. The Certified Nurse Practitioner (CNP) agreed
to the recommendation on 11/19/21 however, the recommendation was not implemented.
On 12/02/21 at 2:37 P.M. interview with the Director of Nursing (DON) confirmed the pharmacy
recommendation was agreed to by the CNP on 11/19/21 but the Depakote Delayed Release tablet had not
been discontinued and replaced with Depakote Sprinkles 250 mg at bedtime as of this time.
2. Review of the medical record for Resident #23 revealed an admission date on 07/01/21 with medical
diagnoses included chronic obstructive pulmonary disease (COPD), psychotic disorder with delusions due
to a known physiological condition, major depressive disorder, vascular dementia with behavioral
disturbance, generalized anxiety disorder, cognitive communication disorder and insomnia.
Review of the plan of care, dated 07/19/21 for Resident #23 revealed the resident took psychotropic
medication related to antianxiety medication and antidepressant medication due to diagnoses of anxiety,
depression, and insomnia. Interventions included obtain lab work as ordered and notify the physician of
abnormal labs.
Review of the quarterly MDS 3.0 assessment, dated 10/09/21 revealed Resident #23 had severely impaired
cognition with a Brief Interview for Mental Status (BIMS) assessment of zero. The resident exhibited
wandering behavior daily.
Review of the current physician's orders for Resident #23 revealed the only order for labs was dated
07/02/21 and included an order for a CBC, CMP, B12, A1c, and lipid panel on the next lab day. There was
no order to draw labs to check for Vitamin D, Depakote, or CBC after 07/02/21.
Review of the pharmacy recommendation, dated 10/05/21 revealed a recommendation to check Resident
#23's Vitamin D level and Depakote levels due to the resident was taking these medications. The
recommendation was agreed to by the CNP on 11/11/21 with an order to check Vitamin D, Depakote, and
CBC labs however, the order had not been implemented as of this date.
On 12/02/21 at 2:37 P.M. interview with the Director of Nursing (DON) confirmed the recommendation for
laboratory testing (Vitamin D, Depakote, and CBC) had not been implemented for Resident #23 as of this
date.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 12 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, review of the facility's contingency medication supply list, review of facility meal
times, policy review and staff interview the facility failed to maintain a medication error rate of less than five
(5) percent (%). The medication error rate was calculated to be 10% and included three medication errors
of 30 medication administration opportunities. This affected one resident (#31) of two residents observed for
medication administration.
Residents Affected - Few
Findings Include:
A review of Resident #31's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses including gastro-esophageal reflux disease (GERD) and adult onset diabetes mellitus.
A review of Resident #31's physician's orders revealed Resident #31 was to receive Humalog insulin
subcutaneously (SQ) before meals (AC) and at bedtime (HS) per sliding scale. The resident also had an
order to receive Lantus insulin 60 units SQ twice daily for her diabetes mellitus and Carafate 1 gram (gm)
by mouth AC and HS for GERD.
A review of Resident #31's medication administration record (MAR) for November 2021 revealed Resident
#31's Lantus was scheduled to be given upon rising. Her Humalog and Carafate were scheduled to be
given at 8:00 A.M.
On 11/30/21 at 8:42 A.M., a medication administration observation was completed for Resident #31. The
resident was administered her morning medications by Registered Nurse (RN) #276. Resident #31 was
administered Carafate 1 gram and Humalog 6 units SQ per sliding scale for a blood sugar of 274 milligrams
(mg)/ deciliter (dl).
At the time of the above observation, Resident #31 had already received her breakfast meal prior to
receiving her medications. The resident's breakfast tray had already been removed from the table in the
dining room where Resident #31 ate the meal. The resident informed the nurse at the time of her
medication administration she had pancakes for breakfast. Continued observation revealed Resident #31
was not administered the scheduled Lantus 60 units. RN #276 searched for Resident #276's Lantus in the
medication administration cart and could not find it. She then checked the medication refrigerator in the
medication storage room on the secured unit to see if Resident #31 had an extra vial of Lantus insulin that
had been sent from the pharmacy but could not find it.
A review of Resident #31's nurses' progress notes revealed a nurse's note dated 11/30/21 at 8:36 A.M.
revealed the resident's Lantus was not given at that time as it was not available.
A review of the facility contingency supply list revealed Lantus insulin was available for use from the
emergency supply box in the medication refrigerator.
A review of the facility's meal times revealed the dining room where Resident #31 ate was to be served
breakfast at 7:15 A.M.
On 11/30/21 at 9:48 A.M., an interview with RN #276 confirmed Resident #31 received both her Carafate
and Humalog insulin after she ate her breakfast. She verified Resident #31's physician's orders
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 13 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
were specific for her to receive both of the medications before her meal. She denied having Lantus insulin
available to give Resident #31 and stated she did not think to check the facility's contingency medication
supply to see if it was available in the emergency box.
On 11/30/21 at 11:15 A.M. the Director of Nursing (DON) was informed the facility medication error rate
was above 5%. The DON confirmed the facility had Lantus insulin available in their emergency supply box
in the refrigerator. She stated all the nurse would have had to do was to pull it out of the refrigerator and
sign the slip to indicate who it was used for. She also acknowledged Resident #31 was to receive her
Carafate and Humalog insulin before she ate her breakfast as ordered by the physician but revealed the
administration times on the MAR were set up for 8:00 A.M. and the dining room where Resident #31 ate
was served breakfast at 7:15 A.M. She agreed it did not make sense to check Resident #31's blood sugar
after she ate requiring her to be covered with extra units of Humalog insulin. She confirmed Carafate was to
be given before meals to help coat stomach ulcers and protect them from acids, enzymes and bile salts
that were generated when eating.
A review of the facility policy on Medication Administration- General Guidelines, revised 11/2018 revealed
medications were to be administered as prescribed. If a medication with a current, active order could not be
located in the medication administration cart, other areas of the medication cart, medication room and
facility should be searched, if possible. Medications were to be administered in accordance with written
orders of the prescriber. Medications were to be administered within 60 minutes of the scheduled time,
except before, with or after meal orders, which were administered based on mealtimes.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 14 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, review of the facility's menu, meal ticket review and staff interview the facility failed to ensure
a resident received the appropriate diet in the form that was required by the resident and ordered by the
physician. This affected one (Resident #1) of four residents reviewed for nutrition.
Findings include:
A review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses including Alzheimer's disease, history of a stroke and dysphagia.
A review of Resident #1's speech therapy discharge summary for dates of service 06/18/21 through
07/06/21 revealed the resident was seen by speech therapy for dysphagia. Discharge recommendations
included the use of a mechanical soft diet with chopped textures. She had previously been on a pureed diet
but was thought to be safe for an upgrade in her diet as she was not showing any signs or symptoms of
aspiration.
A review of Resident #1's active physician's orders revealed the resident was ordered to receive a regular
diet with a mechanical soft texture. The order had been in place since 10/31/21.
A review of Resident #1's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/09/21 revealed the
resident did not have any communication issues and was cognitively intact. She required supervision with
set up help for eating.
A review of Resident #1's care plans revealed she had a care plan in place for the potential for an alteration
in nutrition related to the use of a mechanical soft diet. The interventions included providing the resident
with the diet as ordered.
On 12/01/21 at 8:00 A.M. an observation of Resident #1 revealed she was sitting up in bed with the head of
her bed elevated. The resident had her eyes closed but aroused easily when spoken to. Her breakfast tray
remained on her over bed table that was still in front of her. The resident was noted to have been given a
sausage patty for breakfast without the sausage patty being chopped up as ordered. A review of Resident
#1's meal ticket that was on her breakfast tray revealed she was to receive a mechanical soft diet with
ground meats. Findings were verified by State Tested Nursing Assistant #262.
A review of the facility's spreadsheet for the breakfast meal on the Day 4 cycle menu revealed residents on
a mechanical soft diet were to receive ground sausage links. They were to be given a #8 scoop with two
ounces of gravy instead of two sausage links that a resident on a regular diet should have been given. The
spreadsheet for the breakfast meal for the Day 3 cycle menu revealed sausage patties were served on that
day. The residents on a mechanical soft diet were to receive a #30 scoop of the ground sausage patty with
two ounces of gravy. Residents on a regular diet were to get one sausage patty as Resident #1 was noted
to receive.
On 12/01/21 at 8:21 A.M., an interview with STNA #262 revealed Resident #1 should have had a sausage
patty that was chopped up and not a whole patty as she received. She indicated the last time she worked
Resident #1 did receive ground meats but was not sure why she did not receive that for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 15 of 16
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
366202
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Crystal Care of Coal Grove
813 1/2 Marion Pike
Coal Grove, OH 45638
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
breakfast that morning. She confirmed Resident #1 took a couple bites of her sausage patty and left the
rest on her tray. She denied she questioned the resident receiving a sausage patty even though her meal
ticket clearly indicated she was to receive ground meats.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366202
If continuation sheet
Page 16 of 16
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Back to topCitations
8 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.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
FAQ · About this visit
Common questions about this visit
What happened during the December 7, 2021 survey of CRYSTAL CARE OF COAL GROVE?
This was a inspection survey of CRYSTAL CARE OF COAL GROVE on December 7, 2021. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CRYSTAL CARE OF COAL GROVE on December 7, 2021?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."
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.
SourceView on CMS Care Compare
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.