The Terrace at Crystal: No Sheets for Bariatric Beds - MN
The residents both have morbid obesity. Both are largely dependent on staff for basic care. Both told inspectors, independently, the same thing: the facility just didn't have sheets that fit.
When inspectors visited on June 1, 2026, they found Resident 15 lying in his bariatric bed on top of a blanket, with large sections of the bare mattress exposed on either side. He told them the facility had never put a fitted sheet on his bed because they didn't have any. He has chronic respiratory failure, morbid obesity, chronic pain, and no use of his legs. He cannot get up and fix the blanket himself. He cannot transfer himself. He waits for staff.
The next morning, two nursing assistants came into his room to move him from his bed to his mobility device. The bare mattress was still showing. One of the aides confirmed there was no fitted sheet and said she wasn't sure why.
A third aide, interviewed separately, was sure why.
"We've been asking for bariatric sheets for months," the aide told inspectors. "We only have maybe 3 or 4 sets of bariatric sheets and they are always in room [redacted] because she makes laundry give them back to her." The aide said staff had reported the shortage to the previous administrator and the maintenance supervisor. Nothing changed.
Another aide put it plainly: "This is not a new thing, it's been a problem since January. There are not enough sheets that fit the bariatric beds. We keep telling management they need to buy a bigger size. If there aren't any sheets available to make the bed, we just use a blanket."
January to June. Five months of blankets instead of sheets.
Resident 53 had the same experience. When inspectors found her on the morning of June 1, she was lying on a blanket with parts of the bare mattress exposed beneath her. She told them the facility didn't have sheets that fit her bed, and that she would prefer a fitted sheet, one that actually stayed in place and didn't fall off all the time. She has morbid obesity, anxiety, and sleep deprivation.
Inspectors returned to her room two days later, at 7:40 in the morning. Same blanket. Same exposed mattress. No sheet.
The following morning, a nursing assistant brought Resident 53 her breakfast tray and confirmed to inspectors that there was no sheet on the bed and there should have been.
The director of nursing, when interviewed on June 4, said she would expect all residents to have sheets on their beds.
The facility's own written policy for making a bed lists the required supplies: a pillowcase, two sheets, a blanket if necessary. Sheets are not optional under the policy. They are listed first.
The inspection report classified the violation as causing minimal harm or potential for actual harm. What it describes is two people, both cognitively intact, both aware of their situation, both unable to fix it themselves, lying on institutional mattresses for months while the staff who cared for them kept raising the problem to management and kept being ignored. One resident had apparently claimed the facility's small supply of bariatric sheets for her own room, leaving none for anyone else, and management had not resolved even that.
Resident 53 told inspectors what she wanted. A fitted sheet. One that fit the bed properly and didn't fall off all the time. It was not a complicated request.
As of the inspection, she still didn't have one.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Terrace At Crystal LLC from 2026-06-05 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
THE TERRACE AT CRYSTAL LLC in CRYSTAL, MN was cited for violations during a health inspection on June 5, 2026.
The residents both have morbid obesity.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.