Crystal Place, LLC

What the state also noted

• — The same June 2025 survey cited neglect with actual harm to one resident: a 97-year-old resident who required staff help to toilet was observed saturated with urine from shins to neck with soiled bedding, and staff confirmed no one had assisted the resident to the bathroom between roughly 9:30 p.m. and 7:00 a.m. The resident told the surveyor this happened 'nearly every morning.'
• — The June 2025 survey also cited a missed annual comprehensive assessment, missing weekly medication counts required by residents' service contracts, an incident report not transmitted to the state within one business day because the administrator mis-keyed the fax number, and an unlocked, unattended medication cart plus an unlocked medication storage room.
• — Complaint OK00083544, investigated with the June 2025 survey, was substantiated on two grounds: the state concluded 'the center failed to secure medications and prevent a resident from causing self harm.' Complaint OK00083530 was likewise substantiated for failure to secure medications.
• — Complaint OK00079607 was investigated with the June 2025 survey but the bundle does not separately describe its outcome, so the substantiated-complaint count is a minimum.
• — The June 19, 2025 complaint survey cited an Immediate Jeopardy — the state's most serious level — for medication administration: the center had no self-administration policy, five insulin pens were found unsecured in a resident's unlocked apartment refrigerator, and a resident with type 2 diabetes was found unresponsive with a blood sugar of 23 and two insulin pens plus about five needles in his bed; he died at the hospital.
• — OSDH rejected the facility's first plan of correction for the June survey. A July 16, 2025 letter states the plan 'is not acceptable' because, on the medication storage and security rule, 'There is no remedy to ensure the medication aides are trained appropriately to keep medication carts locked.'
• — An August 20, 2025 revisit again found an unattended, unlocked medication cart containing two vials of insulin, about two months after the June death, with a resident sitting roughly eight feet away. OSDH's cover letter states these deficiencies 'remain uncorrected from our original investigation conducted June 19, 2025,' and the state did not certify correction until September 19, 2025.
• — The April 11, 2025 licensure and complaint survey cited six deficiencies, including two unlocked medication carts with medications and resident MAR/HIPAA information left visible on unlocked computers, no bed-rail risk agreement for a resident with Alzheimer's, a missing significant-change assessment, a resident record that could not be produced, and missing 2024 incident reports.
• — Three different administrators are named on correspondence across the 2025 surveys (Regina Herring in April, Carrie Elmore in early July, Leah Bell from mid-July onward), which suggests leadership turnover during this period. A DON interviewed in April said 'I just started working here.'
• — Portions of the scanned plan-of-correction pages are mirrored and garbled in the OCR; the survey letters, investigative reports and deficiency statements themselves are legible and are the basis for everything above.