Federal inspectors cited the facility for immediate jeopardy violations after discovering the neglected resident, identified as Resident #7, whose necrotic stoma went without adequate medical evaluation despite obvious warning signs.
The facility's Director of Nursing acknowledged that nurses observed the stoma had turned black and developed an odor but completed only basic documentation in nursing notes. No comprehensive assessment was performed to check vital signs, pain levels, bowel sounds, or examine stool appearance in the colostomy bag.
Two physicians consulted by inspectors said the condition demanded urgent intervention.
Physician #1 told inspectors that if a resident had a necrotic stoma with odor that wasn't present before, "they would send them to the emergency room." The doctor called it "an immediate intervention."
Physician #2 explained that while stomas can become discolored, warning signs like fever, bloody stool, or abdominal tenderness indicate infection or reduced blood flow requiring emergency room treatment. They said nurses should call providers immediately when such symptoms develop.
The resident's medical care had already been compromised by medication errors. Resident #7 was supposed to receive Colace, a stool softener, but the Director of Nursing admitted it "was not ordered and should have been." The resident also missed doses of polyethylene glycol, another bowel medication.
These omissions likely contributed to problems visible on the resident's abdominal x-ray, the Director of Nursing told inspectors. The facility had ordered the x-ray and blood work when the resident's regular physician wasn't available.
Staff also failed to administer normal saline at 1:00 p.m. as ordered, documenting that "the resident was not available" even though the Director of Nursing confirmed the resident remained in the facility at that time.
Records show the resident received ondansetron, an anti-nausea medication, twice on consecutive days. The resident also received tramadol, a pain medication, multiple times over two days, suggesting ongoing distress.
The facility's admission assessment had documented Resident #7's stoma as "normal and protruding" with "bowel sounds active" when they arrived. The dramatic deterioration to a blackened, odorous condition represented a significant change that should have triggered immediate medical evaluation.
Inspectors found a second pattern of neglect involving Resident #3, a Medicare Part A patient admitted with multiple cancer diagnoses including malignant tumors of the jaw, mouth, and anus, plus a stage 3 pressure ulcer on the tailbone.
Despite federal requirements for daily skilled nursing assessments during Medicare stays, no documentation existed for assessments from several consecutive days. The traveling Director of Nursing told inspectors they "could not locate the daily nursing assessments" for those dates.
RN #1 described the assessment process as involving observation and communication with residents, using pre-generated questions about pain, skin problems, assistance needs, and oxygen use. The nurse said the last completed assessment on Resident #3 was several days earlier, with night shift responsible for the missing evaluations.
The Director of Nursing acknowledged that daily assessments should have been completed as expected.
Federal regulations require skilled nursing facilities to provide Medicare Part A residents with daily assessments to monitor their condition and ensure appropriate care. The missing documentation suggests Resident #3 went days without proper evaluation despite serious medical conditions requiring close monitoring.
The immediate jeopardy citation indicates inspectors determined the facility's failures posed serious risk of harm to residents. Such violations typically trigger federal oversight and require immediate corrective action to continue receiving Medicare payments.
Both cases reveal systemic problems with basic nursing care at the facility. Staff failed to recognize and respond to obvious medical emergencies, missed required medication administration, and neglected mandatory daily assessments for vulnerable residents with complex medical needs.
The inspection occurred following complaints about the facility's care practices. Federal inspectors found the violations affected few residents but posed immediate danger to those involved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accel At Crystal Park from 2025-10-16 including all violations, facility responses, and corrective action plans.