Average — CMS composite of the measures below.
The next survey window likely opens around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crystal Care Of Coal Grove during CMS and state inspections, most recent first.
Care plans were not developed to address PTSD for one resident or suicidal ideations for another resident. One resident had PTSD, anxiety, depression, and needed staff help with ADLs, but the care plan did not address triggers, behaviors, or staff interventions. Another resident had dementia, anxiety, depression, suicidal ideations, severe cognitive impairment, and was receiving Depakote for suicidal ideations, but no care plan addressed the suicidal ideations.
PRN pain management was incomplete for a resident with CKD, RA, DM, psychosis, and a lung nodule. The MAR showed Tylenol and Tramadol ordered PRN for pain, but there were no pain-level parameters for when to give each medication and no nonpharmacological interventions were ordered. An LPN confirmed the lack of nonpharmacological interventions, and the Administrator confirmed the two PRN pain meds were ordered and given without directions or parameters.
A resident with PTSD, anxiety, and depression had a trauma evaluation documenting emotional abuse history, large-crowd triggers, and symptoms including severe anxiety and sleep difficulty. However, the care plan did not include a specific PTSD plan or identified triggers, and CNAs stated they were not aware of the resident's triggers or related care plan; the Administrator confirmed staff were not aware of the plan.
Failure to Implement Pharmacy Recommendations for Medication Review: The facility did not carry out pharmacy recommendations for two residents during monthly medication review. One resident on divalproex had a signed recommendation for CBC and a Depakote level, but the level was not found in the record. Another resident with schizophrenia had a signed recommendation for a Trazodone dose reduction, but the chart still showed the higher dose and no documentation that the reduction occurred.
A resident with HTN, bipolar disorder, and depression had an active order for Metoprolol 25 mg BID with instructions to hold the dose if pulse was below 60. Review of the MAR and vital signs showed no evidence that the resident's pulse was obtained before Metoprolol was given, and the DON and Administrator confirmed the missing documentation.
Care plans missing for PTSD and suicidal ideations
Penalty
Summary
The facility failed to ensure comprehensive care plans were initiated to address Post Traumatic Stress Disorder (PTSD) and suicidal ideations for two residents. Resident #3 was admitted and later readmitted with diagnoses including PTSD, insomnia, anxiety, depression, diabetes mellitus type two, and bilateral above-the-knee amputations. The five-day Medicare MDS assessment showed the resident was cognitively intact, had no behaviors, and required staff assistance with activities of daily living, but the care plan did not address the cause of the PTSD, resident triggers, reaction behaviors, or staff interventions. Resident #4 was admitted and later readmitted with diagnoses including senile degeneration of the brain, anxiety, suicidal ideations, seizure disorder, chronic kidney disease stage three, dementia, and malignant neoplasm of overlapping sites of the rectum, anus, and anal canal. The quarterly MDS showed severe cognitive impairment with inattention, disorganized thinking, hallucinations, delusions, verbal behaviors toward others, and rejection of care, and the resident was dependent on staff for activities of daily living. Physician orders included Depakote sprinkles for suicidal ideations and depression, but the care plan did not address suicidal ideations. Staff interview confirmed there was nothing on the point of care documentation about suicidal ideations, and the Administrator confirmed the resident did not have a care plan addressing suicidal ideations.
PRN Pain Medications Lacked Parameters and Nonpharmacological Interventions
Penalty
Summary
Safe, appropriate pain management was not provided for Resident #5, who was admitted with diagnoses including chronic kidney disease stage three, unspecified psychosis, rheumatoid arthritis, diabetes mellitus, and malignant nodule of the lung. Review of the MAR showed the resident was ordered Tylenol 650 mg by mouth every 8 hours as needed for pain and Tramadol 50 mg by mouth every 6 hours as needed for pain, but there were no pain level parameters to guide when each medication should be given. The record also showed no nonpharmacological interventions were ordered for pain management. The care plan stated the resident would verbalize adequate relief of pain or cope with incompletely relieved pain and included interventions such as administering medications as ordered, notifying the physician as needed, using nonpharmacological interventions, and observing for signs and symptoms of pain. During interview, the resident denied pain. An LPN confirmed the resident did not have nonpharmacological interventions for pain and stated that if a resident had two PRN pain medications, one or the other would be administered based on the resident's pain level. The Administrator confirmed the resident was ordered and received two different PRN pain medications without directions or parameters for what pain level would warrant each medication.
Failure to Include PTSD Triggers in Care Plan
Penalty
Summary
Provide care or services that was trauma informed and/or culturally competent. Resident #20 was admitted with diagnoses including PTSD, anxiety disorder, and depression, and the medical record showed she was cognitively intact and able to make her needs known. A trauma evaluation documented a history of emotional abuse earlier in life, with triggers including being in large crowds, and symptoms of difficulty sleeping, fear, severe anxiety, and feelings of guilt or shame. However, the care plan did not include a specific plan of care for PTSD and did not identify triggers that could help caregivers avoid re-traumatizing the resident. Certified Nursing Assistants #280 and #410 stated they did not know the resident's specific triggers or the care planning related to PTSD, and the Administrator confirmed the care plan did not include identified triggers and that staff were not aware of the plan of care.
Failure to Implement Pharmacy Recommendations for Medication Review
Penalty
Summary
The facility failed to implement pharmacy recommendations for two residents during monthly drug regimen review. For one resident with chronic kidney disease stage three, unspecified psychosis, rheumatoid arthritis, diabetes mellitus, delusional disorder, schizoaffective disorder, major depressive disorder, and a malignant lung nodule, the MAR showed Divalproex Sodium Sprinkles 500 mg three times daily. A pharmacy recommendation dated 04/05/25 requested a CBC and serum Depakote level on the next lab day, and the physician agreed and signed on 04/22/25. The record showed a CBC was completed, but there was no Depakote level documented in the medical record during 05/25. The Administrator confirmed the signed recommendation and the absence of evidence of a Depakote level in the record. For another resident with hypothyroidism, COPD, atrial fibrillation, and schizophrenia, the quarterly MDS indicated the resident was cognitively intact and required staff assistance with ADLs. A pharmacy recommendation dated 06/24/25 requested a gradual dose reduction of Trazodone, and the physician agreed to decrease the medication to 75 mg at bedtime. However, the current physician orders showed Trazodone 100 mg at bedtime, and the record did not include information showing the medication was reduced as ordered. The Administrator confirmed the signed recommendation and that the resident’s medication was not reduced as ordered by the physician. The facility policy stated the consultant pharmacist reviews each resident’s medication regimen and clinical record at least monthly and communicates recommendations to those with authority or responsibility to implement them in a timely manner.
Failure to Obtain Pulse Before Metoprolol Administration
Penalty
Summary
The facility failed to ensure that vital signs were monitored as ordered before administering medication for one resident. Resident #2 was admitted with diagnoses including hypertension, bipolar disorder, and depression, and the quarterly MDS dated 07/18/25 assessed the resident as having intact cognition. An active physician order dated 11/02/24 directed that Metoprolol 25 mg be given twice daily for hypertension and held if the pulse was below 60. Review of the MAR and recorded vital signs from 09/01/25 through 09/11/25 showed no evidence that the resident's pulse was obtained before Metoprolol was administered. The DON and Administrator confirmed on 09/11/25 at 12:35 P.M. that there was no evidence the resident's pulse had been obtained as ordered prior to administration of Metoprolol.
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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 Coal Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harbor Healthcare Of Ironton | 0.9 mi | ★★★★★ | 0 | 0 |
| Sanctuary At Ohio Valley | 0.9 mi | ★★★★★ | 0 | 0 |
| Oakmont Manor | 2.6 mi | ★★★★★ | 0 | 0 |
| Woodland Oaks | 3.9 mi | ★★★★★ | 0 | 0 |
| Kings Daughters Medical Center | 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 June 2026) and official state health department websites.