Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crystal Oaks during CMS and state inspections, most recent first.
Missing Bed Hold Notices, Transfer Notification, and Discharge Summary Documentation: The facility failed to provide a bed hold policy to two residents when they were transferred to the hospital, failed to give written transfer/discharge notification to one resident, and failed to complete a discharge summary with a recapitulation of stay for a closed record. Records showed multiple hospital transfers for two residents, while another resident's chart lacked a discharge summary or progress note and contained only limited episode documentation.
An LPN and CNAs failed to follow hand hygiene and glove-changing practices during wound care for one resident and urinary catheter care for another. The LPN handled wound supplies, applied treatments, and returned containers to the cart without cleaning them after contact with dirty gloves, while the CNAs continued using the same gloves through catheter care, repositioning, and handling the urinary bag and resident belongings.
The facility failed to maintain sanitary conditions during food service and equipment maintenance, affecting all residents. Staff did not adhere to hand hygiene practices, with instances of using unclean thermometers and handling food without gloves. Ice/water machines and the steam table were not properly cleaned, with debris and dust observed. Interviews confirmed a lack of clarity and documentation regarding cleaning responsibilities, and facility policies were not followed.
The facility failed to develop comprehensive care plans addressing activities for six residents, despite their expressed interest in activities like music and religious participation. Interviews revealed confusion among staff about responsibility for activity care plans, with the MDS Coordinator and Activity Coordinator unaware of their roles. The facility's policy requires care plans to meet residents' needs, but this was not implemented, leading to the deficiency.
The facility failed to provide weekend activities for residents, affecting their quality of life. Despite residents' preferences for engaging activities, only activity packets with coloring sheets and puzzles were provided, which residents found unstimulating. The Activity Director's resignation left only two staff members who did not work weekends, and the Director of Nursing was unaware of the situation. The facility's policy required activities to be offered at convenient times, including weekends.
The facility did not cover a clean laundry cart, risking contamination of residents' personal items. The Housekeeping/Laundry Aide was not instructed to cover the cart, and the Director of Housekeeping/Laundry believed only linens needed covering. The Administrator expected personal laundry to be covered during transport.
The 300 unit shower room in the facility was found to be unsanitary and non-functional, with a strong odor, a dirty and loose toilet, a soiled shower curtain, and mold on the walls. Residents reported a pinhole leak in the shower cord and instances of feces on the floor. The Nurse Manager confirmed these observations, while the DON was unaware of the leak. The Director of Housekeeping acknowledged the need for thorough cleaning despite daily efforts.
A resident with end-stage renal disease felt her dignity was compromised by an Enhanced Barrier Precautions (EBP) sign on her door, which led to privacy concerns and unwanted inquiries about her health. Despite the resident's cognitive intactness and expressed discomfort, facility staff were unaware of the issue, and the signage was maintained as per policy requirements.
The facility failed to deliver mail to residents on Saturdays, affecting their access to important communications. Interviews revealed that mail is only picked up from the post office Monday through Friday, as staff responsible for this task do not work on weekends. This practice potentially impacts all residents, as confirmed by several residents during interviews.
A resident was administered 16 doses of Methotrexate, a high alert chemotherapy medication, instead of the prescribed Metolazone for Congestive Heart Failure. This error led to increased pain, multiple infections, cognitive impairment, skin issues, shortness of breath, swelling, wounds, and ultimately the resident's death. The error was attributed to the similarity in the spelling of the medication names and the lack of a clear policy for reconciling medications from the pharmacy with physician orders. Four Certified Medication Technicians (CMTs) administered the incorrect medication over 16 days without detecting the error. The deficiency was classified as an Immediate Jeopardy (IJ) situation, indicating a serious threat to resident safety.
Missing Bed Hold Notices, Transfer Notification, and Discharge Summary Documentation
Penalty
Summary
The facility failed to provide a bed hold policy upon transfer to the hospital for Resident #7 and Resident #79, both of whom had multiple hospital transfers and returns documented in their records. For Resident #7, the medical record showed three transfers to the hospital and returns to the facility, with no documentation that a copy of the bed hold policy was provided to the resident and/or the resident's representative. For Resident #79, the record showed two transfers to the hospital and returns to the facility, with no documentation that a copy of the bed hold policy was provided. The facility also failed to notify Resident #79 and/or the resident's representative in writing of a transfer or discharge to the hospital. In addition, Resident #136's closed record did not include a discharge summary with a recapitulation of stay describing the resident's course of treatment while residing in the facility. The record showed admission and discharge to another facility with hospice evaluation, but the documentation available included only an order to discharge and a Summary of Episode with no assessment, encounters, goals, functional status, health concerns, medical equipment, medications, plan of treatment, procedures, reasons for referral, or diagnostic results, and no discharge summary or progress note was present.
Infection Control Lapses During Wound and Catheter Care
Penalty
Summary
The facility failed to maintain infection control practices during wound care for one resident and urinary catheter care for another resident. During wound care for Resident #27, the LPN washed hands, set up supplies on a towel-covered bedside table, and then repeatedly handled wound care items with and without changing gloves or sanitizing hands between tasks. The LPN cleaned the wound, applied barrier cream, gentamicin, packing, and alginate, and used the same gloves to reposition the resident and handle linens before removing gloves, sanitizing hands, and washing hands. The LPN then placed the alginate container and wound cleanser back into the treatment cart without cleaning the shared containers, and later stated the containers should have been cleaned before being returned to the cart. During urinary catheter care for Resident #44, two CNAs washed hands and donned gowns and gloves, then performed perineal and catheter care while continuing to use the same gloves through multiple tasks, including cleaning the groin, catheter insertion site, buttocks, removing boots, and moving the urinary bag onto the bed. One CNA later drained the urine collection bag, then with the same gloves adjusted the resident's pillow and blanket and moved the bedside table closer. During interview, the CNA stated gloves should have been removed and hands sanitized after moving the bed, touching the blanket, and before beginning catheter care, and that hands should have been sanitized with new gloves placed after emptying the catheter bag and before touching the resident's pillow and blanket. The Administrator and DON stated they would expect staff to use proper hand hygiene during wound and urinary catheter care and to clean items and containers after handling them with dirty gloves before returning them to the treatment cart.
Sanitation Deficiencies in Food Service and Equipment Maintenance
Penalty
Summary
The facility failed to maintain sanitary conditions during food service and distribution, as well as in the maintenance of kitchen equipment, which could potentially affect all 117 residents receiving meals and beverages. Observations revealed that staff did not adhere to proper hand hygiene practices. For instance, a cook used a thermometer without cleaning it between uses, and a dietary aide handled various items without sanitizing her hands, including touching residents' drinks and food items directly without gloves. The facility's policy explicitly prohibits bare hand contact with food and requires gloves to be worn when handling food directly. Additionally, the facility did not properly clean and maintain the ice/water machines and steam table, leading to potential contamination. Observations showed crystallized debris and dust on the ice/water machines, with missing chute covers and dirty reservoir grates. Interviews with housekeeping and maintenance staff revealed a lack of clarity and documentation regarding the cleaning responsibilities and schedules for these machines. The steam table area was also found to be unsanitary, with soiled trays, food particles, and stained surfaces, indicating inadequate cleaning practices. Interviews with staff, including the Dietary Manager and Director of Nursing, confirmed the deficiencies in maintaining sanitary conditions. The Dietary Manager acknowledged the expectation for staff to sanitize hands between residents and to avoid direct contact with food without gloves. The Director of Nursing confirmed the poor condition of the ice machine, and the Maintenance Director was unsure about the maintenance responsibilities. The facility's policies on food preparation and ice machine maintenance were not being followed, contributing to the unsanitary conditions observed.
Failure to Develop Comprehensive Activity Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed activities for six residents, potentially resulting in unmet activity needs. The residents involved had various diagnoses, including Parkinson's Disease, traumatic brain injury, schizophrenia, intestinal adhesions, atrial fibrillation, and hemiplegia. Their cognitive statuses ranged from moderately impaired to cognitively intact, as indicated by their BIMS scores. Despite the residents expressing the importance of engaging in activities such as listening to music, keeping up with the news, participating in religious activities, and going outside, their care plans lacked specific focus areas or interventions related to these activities. Interviews with facility staff revealed a lack of clarity and responsibility regarding the development and implementation of activity care plans. The MDS Coordinator confirmed that she did not write care plans for activities, and the former Activities Director was responsible for this task. However, the current Activity Coordinator was unaware of the requirement to complete care plans for activities. The Director of Nursing also stated she was unaware that activity care plans were not being completed. The facility's policy on comprehensive, person-centered care plans, revised in March 2022, mandates that care plans include measurable objectives and timetables to meet residents' needs. The policy specifies that care plans should describe services to maintain residents' highest practicable physical, mental, and psychosocial well-being. Despite this policy, the facility did not ensure that activity care plans were developed and implemented for the residents, leading to the identified deficiency.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide a program of activities to support residents in their choice of activities on weekends, affecting six residents who attended a group meeting. These residents expressed the importance of engaging in activities such as keeping up with the news, listening to music, participating in group activities, going outside, and attending religious services. Despite these preferences, the facility did not offer activities on weekends, leaving residents without meaningful engagement during these times. Interviews revealed that the Activity Director had resigned, leaving only two staff members in the department, who did not work on weekends. The Activity Coordinator confirmed that activity packets, including coloring sheets and puzzles, were left at nurses' stations for residents on weekends. However, residents reported that these packets did not stimulate them and expressed a desire for evening activities. Additionally, a church group provided services every other Sunday, but residents were unable to receive communion due to the absence of staff to ensure safety during the service. The Director of Nursing was unaware of the lack of weekend activities and assumed that communion was being provided. The Administrator acknowledged the issue and mentioned alternating schedules for weekends and evenings. The facility's activity calendar listed activity packets and coloring as weekend activities, and chapel services were scheduled bi-weekly. The facility's policy stated that activities should meet residents' interests and be offered at convenient times, including evenings, holidays, and weekends.
Uncovered Laundry Cart Leads to Potential Contamination
Penalty
Summary
The facility failed to ensure that a clean laundry cart was covered to prevent potential contamination of residents' personal items. During an observation, an uncovered clean laundry cart was seen passing through the dining room, containing personal items. Interviews revealed that the Housekeeping/Laundry Aide was not instructed to cover the clean laundry on the cart, and the Director of Housekeeping/Laundry believed that only linens needed to be covered, not personal laundry. The facility outsourced linens and was only responsible for washing personal laundry. The Administrator expected that residents' personal laundry should be covered during transportation from the laundry to the residents' rooms.
Unsanitary Conditions in 300 Unit Shower Room
Penalty
Summary
The facility failed to maintain a functional and sanitary environment in one of its shower rooms, specifically the 300 unit shower room. Observations revealed a strong unrecognizable odor, a dirty toilet with stains that was loose from the floor, and a heavily soiled shower curtain. The shower walls were observed to have a pinkish/orange and black substance, and a dead bug was found on the floor. These conditions were confirmed by the Nurse Manager for the 300, 400, and 500 halls during the observation. Interviews with six residents who used the 300-hall shower room corroborated these findings, as they described the shower rooms as "nasty" and reported a pinhole leak in the shower cord that sprayed them in the face. They also noted the presence of brown stains on the shower curtain, dirty floors, and instances of feces on the floor. The Director of Nursing acknowledged awareness of the shower room's condition but was unaware of the hole in the shower line. The Director of Housekeeping/Laundry confirmed the need for scrubbing and acknowledged the presence of black mold, despite daily cleaning by housekeeping staff. The Administrator stated that shower rooms should be cleaned prior to each resident's use.
Resident Dignity Compromised by EBP Signage
Penalty
Summary
The facility failed to uphold a resident's right to dignity and respect by posting an Enhanced Barrier Precautions (EBP) sign on the door of a resident with end-stage renal disease. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, expressed that the sign was an invasion of privacy and led to unwanted inquiries about her health status, specifically regarding COVID-19. Despite the resident's concerns, the Assistant Administrator acknowledged the issue but indicated that the signage was a requirement. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed a lack of awareness regarding the resident's concerns about the EBP sign. The DON recognized the dignity issue posed by the sign, while the ADON was unaware that the signage was not mandatory. The facility's policy on dignity emphasized the importance of promoting residents' well-being and self-esteem, while the EBP policy required signage to indicate necessary precautions and personal protective equipment (PPE).
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received mail delivery on Saturdays, which is a deficiency in providing reasonable access to communication methods. This issue was identified through record reviews and interviews with residents and staff. The facility's practice of not delivering mail on Saturdays potentially affects all 117 residents, as it could delay the receipt of important business documents and family communications. During a group interview, four residents confirmed that they do not receive mail or package deliveries on Saturdays because the activity staff, responsible for mail delivery, do not work on weekends. The Assistant Administrator was interviewed and stated that she was unaware of the requirement to deliver mail on Saturdays. The facility uses a PO box at the post office, and mail is typically picked up by the Administrator, Assistant Administrator, or Human Resources staff from Monday to Friday. Since these staff members do not work on Saturdays, there is no one available to collect the mail from the post office, resulting in the lack of mail delivery to residents on that day.
Medication Administration Error Involving Methotrexate
Penalty
Summary
The facility failed to ensure one resident (Resident #1) was free from significant medication error when staff administered 16 doses of Methotrexate, a high alert chemotherapy medication, instead of the prescribed Metolazone for Congestive Heart Failure. This error resulted in increased pain, multiple infections, and ultimately the resident's death. The resident initially admitted alert, oriented, continent, and ambulatory but later developed cognitive impairment, skin issues, shortness of breath, swelling, and wounds. The pharmacy alerted the facility to the error after the resident exhibited further decline, including blood clotting issues and ultimately passing away. Staff members, including four Certified Medication Technicians (CMTs), administered the incorrect medication over 16 days without detecting the error. Interviews revealed that the medication card and the prescribed medication were closely spelled, leading to a misreading of the card. The facility lacked a clear policy for reconciling medications received from the pharmacy with physician orders, contributing to the oversight. The physician emphasized the severity of the error, noting that the resident's decline and eventual death were consistent with the toxic effects of high doses of Methotrexate. The deficiency was classified as an Immediate Jeopardy (IJ) situation, indicating a serious threat to resident safety. The facility's failure to verify medications correctly, inadequate staff training, and lack of oversight in medication administration processes were key factors contributing to the significant medication error.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Festus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fountainbleau Nursing Center | 0.3 mi | ★★★★★ | 12 | 0 |
| Superior Manor Of Festus, Llc | 1.1 mi | ★★★★★ | 0 | 0 |
| Festus Manor | 1.7 mi | — | 0 | 0 |
| Scenic Wellness And Rehabilitation Center | 4.3 mi | ★★★★★ | 0 | 0 |
| Baisch Nursing Center | 9.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.