Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with hemiplegia and hemiparesis developed an open wound on the left upper extremity that was identified by an LPN, but the physician was not notified and no treatment orders were obtained until several days later. The wound progressed to a Stage IV pressure ulcer requiring surgical debridement. Interviews with staff and record reviews confirmed that facility policy for timely assessment and physician notification was not followed.
The facility experienced repeated deficiencies in Activities of Daily Living (ADL) over three annual surveys due to an ineffective Quality Assurance and Performance Improvement (QAPI) program. Despite meetings to address issues, monitoring for previous deficiencies was unclear, and communication problems between nurses and CNAs were identified. The Corporate Nurse's rounds found ADL issues related to nails and shaving, which were inconsistently monitored, as confirmed by the CASPER3 report.
The facility failed to inform staff and visitors about residents in Transmission-Based Precautions (TBP) for COVID-19. During a COVID-19 outbreak, signage indicating TBP status was missing from residents' doors, as confirmed by staff interviews and observations. The Assistant Director of Nurses/Infection Preventionist admitted to not ensuring signage was posted after returning from a COVID-19 illness. The facility's COVID-19 vaccination rates were 66% in 2023 and 76% in 2024.
The facility failed to implement its Infection Control Program during a COVID-19 outbreak, as evidenced by the lack of signage on residents' doors under Transmission-Based Precautions and insufficient communication with staff. The Infection Preventionist did not conduct surveillance or provide in-service training, and the outbreak was only communicated via text message. Staff expressed concerns about the lack of information, impacting their ability to prevent infection spread. The facility had 27 positive COVID-19 cases among residents.
The facility failed to implement ADL care plans for several residents, resulting in unmet personal care needs. A resident with Diabetes Mellitus did not receive toenail care as required, while another with impaired mobility had long fingernails despite care plan instructions. Additionally, a resident with a self-care deficit had untrimmed nails and facial hair, and another resident's request for toenail trimming was unmet. A resident requiring a hand splint did not have it applied as per the care plan. These deficiencies were confirmed by facility staff.
The facility failed to provide adequate personal hygiene care for four residents, including nail care and shaving. A resident with diabetes had not received toenail care, resulting in a jagged toenail and the loss of another. Another diabetic resident had long fingernails, posing a risk of scratching. A third resident had not been shaved or had nails trimmed for over two months, and a fourth resident had been requesting toenail trimming for over two months. The facility lacked a routine schedule for these services, leading to a deficiency in maintaining personal hygiene standards.
The facility compromised resident dignity by placing incorrect MDRO signs on the doors of 12 residents who did not have MDRO. Staff interviews confirmed the signs were used for residents needing Enhanced Barrier Precautions (EBP) instead. The Assistant Director of Nurses/Infection Preventionist acknowledged the error, and the Administrator confirmed the signs were a dignity issue.
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNOC) to two residents before their discharge from Medicare Part A services, as required by policy. The Business Office Manager was unaware of the requirement, leading to the omission. The Administrator confirmed the oversight, highlighting a gap in communication and awareness regarding the discharge process.
A facility failed to secure a resident's electronic health records, leaving their EMAR visible on an unattended medication cart. The resident's personal information, including name, medications, and room number, was accessible to passersby. A nurse confirmed the oversight, and the ADON noted that a privacy button should have been used to secure the information.
The facility failed to maintain a sanitary and comfortable environment, with issues such as flies in two residents' rooms, a leaking air conditioning unit, a foul odor and dried stool in another room, and a resident's fan covered in dust. Housekeeping and maintenance challenges were noted, with staff unaware of some issues and no additional measures taken to address them.
The facility failed to accurately code the MDS for four residents, leading to discrepancies in their medical records. One resident was incorrectly coded as taking an anticoagulant instead of an antiplatelet, while another was mistakenly recorded as receiving anticoagulant medication. A third resident's mental illness diagnosis was not properly documented, and a fourth resident's functional limitations were inaccurately reported. These errors were confirmed by facility staff, emphasizing the need for accurate MDS coding to ensure appropriate care.
A resident with diabetes did not receive appropriate foot care, as her toenails were long and jagged, and she had not seen a podiatrist recently. The RN and ADON confirmed the need for toenail trimming, but there was no schedule for regular checks. The resident had not seen a podiatrist since May, and the lack of care may have contributed to the loss of a toenail.
A resident with Hemiplegia and Hemiparesis was not provided with a prescribed left-hand splint, which was to be worn daily to maintain range of motion. Observations and staff interviews revealed that the splint was not applied as ordered, with staff misunderstanding the frequency of application. The resident, who was moderately cognitively impaired, confirmed the lack of splint application.
The facility failed to maintain effective pest control against flies, with multiple sightings in a resident room. Observations showed flies on bedspreads, curtains, and a meal tray, despite daily cleaning efforts. Staff interviews confirmed the ongoing issue, exacerbated by residents' behaviors contributing to uncleanliness. The maintenance staff was unaware of the problem, and the Administrator had not been informed of any concerns. The pest control company had visited, but no extra measures were taken.
A cognitively impaired resident, temporarily moved due to a bathroom leak, repeatedly attempted to return to her previous room. Despite staff observations, no increased monitoring was implemented. The resident was later found exiting the room where another resident was discovered with a pillow and sheet covering her face. The incident revealed a lack of communication and supervision adjustments, contrary to the facility's safety policy.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely assessment, physician notification, and initiation of appropriate treatment for a pressure ulcer in one resident. According to the facility's policy, licensed nurses are required to conduct weekly skin integrity checks, document findings, and notify the physician to obtain treatment orders if a new wound is identified. On 1/17/25, an LPN documented an open wound with sanguineous drainage on a resident's left upper extremity and initiated first aid, but there was no documentation that the physician was notified or that treatment orders were obtained at that time. The Treatment Administration Record confirmed that no wound care treatment orders were in place from 1/17/25 until 1/22/25. Further review revealed that the wound was later assessed by a wound care physician on 1/22/25, who identified it as a Stage IV pressure ulcer requiring surgical debridement. Interviews with the LPN, the treatment nurse, and the DON confirmed that the physician was not notified when the wound was first identified and that treatment orders were not obtained until several days later. The resident involved had a history of hemiplegia and hemiparesis following a cerebral infarction and was cognitively intact at the time of the incident.
Repeated ADL Deficiencies Due to Ineffective QAPI Program
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies in Activities of Daily Living (ADL) over the last three annual surveys. The facility's policy on QAPI lacked a revision date, and the purpose statement indicated a system for improving resident care. However, interviews revealed that the QAPI committee met with department heads after the last survey in June 2023 and again in July 2023 to address trending issues. By September 2023, the focus had shifted back to routine matters, and it was unclear if monitoring for previous deficiencies continued. The Corporate Nurse suggested that the repeat deficiencies might be due to changes in administration, including a new Administrator and Assistant Director of Nurses (ADON). Interviews with the Administrator and Corporate Nurse highlighted communication issues between nurses and Certified Nursing Assistants (CNAs) and inadequate supervision of CNAs by nurses as potential causes for the repeated ADL deficiencies. The Corporate Nurse's rounds in February and April 2024 identified ADL issues related to fingernails, toenails, and shaving, which were addressed by Registered Nurses (RNs) but not consistently monitored. The CASPER3 report confirmed ADL deficiencies in the facility's last two annual surveys, indicating a persistent problem in maintaining adequate ADL care for residents.
Failure to Inform Staff and Visitors of COVID-19 Precautions
Penalty
Summary
The facility failed to inform staff and visitors about residents who were in Transmission-Based Precautions (TBP) due to COVID-19. This deficiency was identified for six residents who tested positive for COVID-19. The facility's policy required signage to be posted to inform about infection control precautions, but during an observation, it was noted that there was no signage on the residents' doors indicating they were in TBP. Interviews with staff, including a CNA and the Assistant Director of Nurses/Infection Preventionist, confirmed the lack of signage and awareness of the TBP status of residents. The facility was experiencing a COVID-19 outbreak, with approximately 30 residents testing positive. The Assistant Director of Nurses/Infection Preventionist admitted to failing to ensure that the necessary signage was posted after returning to work following her own COVID-19 illness. The Administrator also confirmed the oversight and acknowledged the need for stricter infection control measures. The facility's COVID-19 vaccination rates were reviewed, showing a rate of 66% in 2023 and 76% in 2024. The deficiency was further supported by record reviews of resident testing and admission records.
Inadequate Implementation of Infection Control Program During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure the Infection Preventionist fully implemented the Infection Control Program during a COVID-19 outbreak. The facility's policy required signage to be posted to prevent the spread of germs and protect against COVID-19, but during the survey, it was observed that there were no signs on residents' doors indicating they were under Transmission-Based Precautions. The Assistant Director of Nurses/Infection Preventionist admitted to not conducting surveillance for the outbreak and failing to ensure signage was posted. Additionally, communication about the outbreak was insufficient, as it was only conveyed through a text message to staff, and no in-service training was conducted. Interviews with staff, including a Certified Nurse Assistant and an Occupational Therapist, revealed concerns about the lack of communication and signage, which hindered their ability to prevent the spread of infection. The Occupational Therapist specifically noted that the facility did not inform therapy staff about the outbreak, impacting their ability to take necessary precautions. The Administrator acknowledged the need for stricter infection control measures. The last in-service training related to infection control was conducted on October 9, 2024, and the facility's records showed 27 positive COVID-19 cases among residents as of October 16, 2024.
Failure to Implement ADL Care Plans
Penalty
Summary
The facility failed to implement Activities of Daily Living (ADL) care plans for several residents, leading to deficiencies in personal care. Resident #11, who has Diabetes Mellitus, had not received toenail care as per her care plan, which required regular monitoring and trimming by a podiatrist or foot care nurse. Observations revealed her toenails were long and jagged, and she had not seen a podiatrist since May 2023. The RN and MDS Nurse confirmed that the care plan was not followed, as the resident did not receive the necessary toenail care. Resident #13, with a self-care deficit due to impaired mobility and other conditions, also did not receive proper nail care. His care plan specified that nails should be checked and trimmed on bath days, but observations showed his fingernails were long. The RN and MDS Nurse confirmed that the care plan was not adhered to. Similarly, Resident #47, who has a self-care performance deficit, had long fingernails and facial hair, contrary to his care plan preferences. He reported that CNAs did not offer to shave him or cut his nails, and the ADON confirmed the care plan was not followed. Resident #51 had been requesting toenail trimming for over two months, but her care plan for nail care was not implemented, as confirmed by the ADON. Additionally, Resident #62, who requires a hand splint due to hemiplegia, was not wearing the splint as per his care plan. The CNA and ADON confirmed the splint was not applied as required. These failures indicate a lack of adherence to individualized care plans, resulting in unmet personal care needs for the residents involved.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care for four residents, specifically in the areas of nail care and shaving. Resident #11, who is non-verbal and has diabetes, had not received toenail care, resulting in a jagged toenail and the loss of another toenail. The resident had not seen a podiatrist since May 2023, and the facility lacked a schedule for regular toenail checks and trimming. The Assistant Director of Nursing (ADON) confirmed that the lack of nail care could have contributed to the resident losing her toenail. Resident #13, also diabetic, was observed with long fingernails, which posed a risk of scratching. The Registered Nurse (RN) and ADON confirmed that the nails should be checked weekly and trimmed by a nurse, but there was no routine task set up for diabetic residents to receive nail care. Resident #47 had not been shaved or had his nails trimmed for over two months, despite expressing a preference for short nails and a clean shave. The Certified Nurse Aide (CNA) and ADON confirmed that it was the CNA's responsibility to provide these services, but they had not been performed. Resident #51, who is not diabetic, had been requesting toenail trimming for over two months. Her toenails were long and jagged, with the potential to cause skin issues. The Licensed Practical Nurse (LPN) confirmed there was no medical reason preventing the trimming of her nails, and the CNA was unaware of why the nails had not been trimmed. The facility's failure to provide routine nail care and shaving services for these residents highlights a deficiency in maintaining personal hygiene standards.
Inappropriate MDRO Signage Compromises Resident Dignity
Penalty
Summary
The facility failed to uphold residents' dignity by incorrectly placing Multi Drug Resistant Organism (MDRO) signs on the doors of 12 residents who did not have MDRO. This action was observed during an initial tour, where it was noted that rooms 110, 111, 122, 125, 128, 132, 208, 215, 218, 223, 225, and 228 had these signs. Interviews with staff, including a Registered Nurse and the Assistant Director of Nurses/Infection Preventionist, confirmed that the signs were mistakenly used for residents requiring Enhanced Barrier Precautions (EBP), not because they had MDRO. The staff acknowledged that the signs were inappropriate and could compromise the dignity of the residents. Further interviews revealed that the facility's policy on resident rights emphasizes the importance of treating residents with dignity and respect. The Assistant Director of Nurses/Infection Preventionist admitted to having the correct signs for EBP but failed to use them, leading to the incorrect signage. The Administrator also confirmed that the MDRO signs posed a dignity issue for the residents. The MDRO signage in question prominently stated that MDROs are a threat to residents, which was misleading and inappropriate for those who did not have the condition.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNOC) to two residents, Resident A and Resident B, who were reviewed for beneficiary notices. According to the facility's policy, a NOMNOC must be delivered at least two calendar days before Medicare-covered services end. However, the Business Office Manager (BOM) did not provide the required NOMNOC to either resident. Resident A had a Medicare Part A stay from June 7 to July 19, and Resident B from June 14 to June 21, with no supporting documentation such as a NOMNOC or Advanced Beneficiary Notice (ABN) provided. During an interview, the BOM confirmed that both residents were discharged from skilled services and the facility when their therapy goals were met, with Resident A having 58 skilled days remaining and Resident B having 93 skilled days remaining. The BOM admitted to not being aware of the requirement to provide a NOMNOC and mistakenly believed it was only necessary for residents under managed care. The Administrator also acknowledged that the NOMNOCs should have been provided prior to discharge, indicating a lack of awareness and communication regarding the discharge process from Medicare Part A services.
Failure to Secure Resident's Electronic Health Records
Penalty
Summary
The facility failed to secure electronic health records, compromising the privacy and confidentiality of a resident's medical information. During an observation, a computer on an unattended medication cart in the East Short Wing was found with the Electronic Medication Administration Record (EMAR) of a resident visible on the screen. This information included the resident's name, medications, and room number, and was accessible to anyone passing by. A registered nurse confirmed that the EMAR was visible and acknowledged that it should have been closed when she was away from the cart. The Assistant Director of Nurses also confirmed that resident information should not be left visible on the screen and that a privacy button should be used to secure the information when the nurse steps away. The resident involved had been admitted with diagnoses including Aphasia, Cerebral infarction, and Traumatic Hemorrhage of Cerebrum.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for its residents, as evidenced by multiple deficiencies observed during the survey. In the case of two residents sharing a room, flies were observed on their beds, privacy curtains, and meal trays. Housekeeping staff confirmed the ongoing issue with flies, attributing it to frequently opened doors at the back of the building. Despite daily cleaning efforts, the room remained unclean due to the residents' behaviors, which included smearing feces. The Assistant Director of Nursing (ADON) and the Administrator were unaware of any additional measures taken to address the fly problem. Another resident's room had a leaking air conditioning unit, with dirty sheets placed underneath to capture the water. Housekeeping staff confirmed the issue, noting the lack of a full-time maintenance person to address such problems. The maintenance staff, who visited the facility once a week, was not informed of the leaking unit, and no repair request was submitted. The Administrator acknowledged the need for equipment to be in good repair but was unaware of the specific issue in this resident's room. Additional deficiencies included a resident's room with a foul odor and dried brown spots on the floor, suspected to be stool. The ADON confirmed the unacceptable conditions and emphasized the shared responsibility of staff to maintain cleanliness. Another resident's personal fan was covered in thick black dust, despite repeated requests for cleaning. Housekeeping staff acknowledged the oversight, recognizing the potential health risk posed by the dust. These observations highlight the facility's failure to uphold a clean and safe environment for its residents.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for four residents, leading to discrepancies in their medical records. Resident #13 was incorrectly coded as taking an anticoagulant when they were actually receiving an antiplatelet medication, Aspirin. This error was confirmed by the RN/MDS nurse and the Assistant Director of Nurses, who emphasized the importance of accurate MDS coding. Similarly, Resident #47 was mistakenly coded as receiving anticoagulant medication during a 7-day observation period, which was not the case according to the Medication Administration Record. The MDS Coordinator acknowledged this error. Resident #56's MDS was inaccurately coded, failing to identify a diagnosis of mental illness as defined by PASRR, despite documentation from the PASRR Office confirming the diagnosis of schizophrenia. The RN/MDS nurse verified this coding error. Additionally, Resident #62's MDS inaccurately indicated no functional limitation in range of motion, despite a physician's order for a hand splint due to hemiplegia and hemiparesis. The RN/MDS nurse confirmed the incorrect coding, highlighting the need for accurate representation of residents' conditions to ensure appropriate care and services.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident #11, who was one of four sampled residents. The facility's Foot Care policy, revised in October 2022, mandates that residents receive foot care and treatment in accordance with professional standards of practice, including assistance in making appointments with specialists as needed. However, during an observation and interview, Resident #11 revealed that her left great toenail was long and jagged, and she had not seen a podiatrist recently nor could she recall the last time her toenails were cut. Additionally, she had lost the toenail on her left fifth toe, which was covered with a bandage. The Registered Nurse (RN) and the Assistant Director of Nursing (ADON) confirmed that Resident #11's toenails were in need of trimming and that the nursing staff is responsible for trimming toenails for diabetic residents. Despite this, there was no schedule for regular toenail checks, and the resident had not seen a podiatrist since May 1, 2023. The ADON acknowledged that the lack of foot and nail care could have contributed to the loss of the toenail. Resident #11, who is cognitively intact with a BIMS score of 13, was admitted to the facility in January 2016 with a diagnosis of Diabetes Mellitus.
Failure to Apply Prescribed Splint for Resident
Penalty
Summary
The facility failed to provide the necessary care and equipment to ensure a resident maintained and improved their range of motion (ROM) and mobility. Specifically, Resident #62, who was admitted with a diagnosis of Hemiplegia and Hemiparesis following a nontraumatic intracranial hemorrhage, was observed without a left-hand splint, which was prescribed to be worn daily. The physician's order required the splint to be applied before breakfast and removed after dinner daily, with skin hygiene provided before and after wear. However, observations on 10/22/24 revealed that the splint was not in use, and interviews with staff confirmed that the splint was not applied as ordered. Interviews with various staff members, including a CNA, LPN, Occupational Therapist, and the Assistant Director of Nursing, confirmed the oversight. The CNA mistakenly believed the splint was only to be applied on specific days, while the LPN and Occupational Therapist confirmed the daily requirement. The ADON acknowledged the failure to follow the physician's orders, which could lead to a decline in the resident's ROM. The resident, who was moderately cognitively impaired, also confirmed that staff did not apply the splint as required.
Failure to Maintain Effective Pest Control Against Flies
Penalty
Summary
The facility failed to maintain an effective pest control regimen against flies, as evidenced by multiple fly sightings in the room of two residents. Observations revealed that one resident was lying in bed with flies on the bedspread and privacy curtain, while the other resident had flies on the bedspread, privacy curtain, footboard, and hovering over a bin of shoes. Interviews with housekeeping staff and the Assistant Director of Nursing (ADON) confirmed that flies had been an ongoing issue in the room, despite daily cleaning efforts. The ADON noted that frequently opened doors might be contributing to the fly problem. Further observations showed flies landing on a resident's meal tray while they were eating, posing a potential risk for illness. Interviews with a Certified Nurse Aide (CNA) and the ADON revealed that both residents had behaviors that contributed to the room's uncleanliness, such as smearing feces and discarding briefs on the floor. The maintenance staff, who had been filling in since February, was unaware of the fly issue, and the Administrator stated she had not been informed of any concerns regarding flies. The pest control company had visited recently, but no additional measures were taken to address the fly activity.
Inadequate Supervision Leads to Resident Incident
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to reduce the risk of accidents and hazards for a cognitively impaired ambulatory resident. The incident involved a resident who was temporarily moved to another room due to a bathroom leak. Despite being informed of the reason for the move, the resident, who had a history of confusion and forgetfulness, repeatedly attempted to return to her previous room. Staff members, including a CNA and an LPN, observed these attempts but did not implement increased monitoring or supervision to prevent potential harm. On the morning of the incident, the resident was found exiting her previous room, where another resident, who was bed-bound and severely cognitively impaired, was discovered with a pillow and sheet covering her face. The LPN and a CNA responded immediately to remove the items and calm the resident. The incident highlighted a lack of communication and coordination among staff, as the Director of Nursing and the Licensed Social Worker were unaware of the resident's repeated attempts to return to her previous room and her distress over the move. The facility's policy on safety and supervision emphasizes the need for individualized supervision based on assessed needs and environmental hazards. However, the staff did not adjust the level of supervision for the resident despite her cognitive impairment and repeated attempts to enter her previous room. This oversight resulted in a failure to prevent a potentially dangerous situation, as evidenced by the incident involving the two residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greenwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverview Nursing & Rehabilitation Center | 0 mi | ★★★★★ | 0 | 0 |
| Golden Age Nursing Home | 1.3 mi | ★★★★★ | 3 | 0 |
| Middleton Oaks Health And Rehabilitation | 24.3 mi | ★★★★★ | 4 | 0 |
| Vaiden Community Living Center | 25.8 mi | ★★★★★ | 1 | 0 |
| Grenada Living Center | 26.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Crystal Rehabilitation And Healthcare Center.
100% money-back within 48 hours.
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.