Crystal Care of Coal Grove

Name: Crystal Care of Coal Grove
Address: 813 1/2 MARION PIKE, Coal Grove, OH, 45638, US
Telephone: 7405320449

813 1/2 Marion Pike, Coal Grove, OH 45638 · Lawrence County · 57 certified beds · avg 51 residents/day · certified since Aug 10, 2000

Part of chain: HILLSTONE HEALTHCARE (9 facilities, chain avg rating 3.9★)

3/5

Health inspection rating (on-site)

Serious findings on record

$159,708

Fines, last 3 years

2.96

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Mar 4, 2024 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Apr 16, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (25)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Sep 11, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Sep 11, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it.
Sep 11, 2025	D · Potential for harm, one-off	The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from.
Sep 11, 2025	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Sep 11, 2025	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Mar 26, 2024	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Mar 26, 2024	D · Potential for harm, one-off	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Mar 4, 2024	▲ J · Immediate jeopardy, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Oct 19, 2023	E · Potential for harm, repeated	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Oct 19, 2023	E · Potential for harm, repeated	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Oct 19, 2023	E · Potential for harm, repeated	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Oct 19, 2023	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Oct 19, 2023	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Oct 19, 2023	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Oct 19, 2023	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Oct 19, 2023	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Oct 19, 2023	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Dec 7, 2021	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Dec 7, 2021	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Dec 7, 2021	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Dec 7, 2021	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Dec 7, 2021	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Dec 7, 2021	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Dec 7, 2021	D · Potential for harm, one-off	The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Dec 7, 2021	C · Minimal risk, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (9 → 5).

Year	Citations	Serious (G–L)	Worst severity that year
2021	8	0	D
2023	9	0	E
2024	3	1	J ▲
2025	5	0	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $159,708, plus 1 Medicare payment denial period.

Date	Type	Amount / length
Mar 4, 2024	Fine	$159,708
Mar 4, 2024	Payment Denial	18 days from Mar 29, 2024

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Ohio avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	2.96	3.45	3.95	bottom 22% in Ohio; bottom 12% in the U.S.
Registered Nurse hours	0.41	0.60	0.69	bottom 22% in Ohio; bottom 24% in the U.S.
Weekend total nurse staffing	2.69	3.07	3.50	bottom 26% in Ohio; bottom 16% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.24	0.42	0.48	bottom 17% in Ohio; bottom 20% in the U.S.
Total nursing staff turnover (%)	48.8	48.7	45.8	bottom 49% in Ohio; bottom 40% in the U.S.
RN turnover (%)	0.0	43.9	42.9	—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.16, RN 0.44, weekend 2.87. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Bergsten, Paul	Individual	Corporate Officer	NOT APPLICABLE	02/01/2016
Bergsten, Paul	Individual	Operational/Managerial Control	NOT APPLICABLE	02/01/2016
Dapore, Matthew	Individual	Corporate Officer	NOT APPLICABLE	02/01/2016
Dapore, Matthew	Individual	Operational/Managerial Control	NOT APPLICABLE	02/01/2016
Detty, Peter	Individual	W-2 Managing Employee	NOT APPLICABLE	03/01/2016
Ramsey, Tara	Individual	W-2 Managing Employee	NOT APPLICABLE	02/16/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"How do you assess and manage residents' pain, especially for those who have trouble communicating?"
"How do you learn about each resident's background and history, and how does that shape their care?"
"Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
"How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Harbor Healthcare of Ironton	0.9 mi	Ironton, OH	★★★★☆	3/5
Sanctuary at Ohio Valley	0.9 mi	Ironton, OH	★★★★☆	4/5
Oakmont Manor	2.6 mi	Flatwoods, KY	★★★☆☆	3/5
Woodland Oaks	3.9 mi	Ashland, KY	★★★★☆	4/5
Kingsbrook Lifecare Center	5.7 mi	Ashland, KY	★★★★☆	3/5
Wurtland Nursing and Rehabilitation	6.9 mi	Wurtland, KY	★☆☆☆☆	1/5
Boyd Nursing and Rehabilitation	10.7 mi	Ashland, KY	★★★☆☆	2/5
Riverview Post Acute	10.9 mi	South Point, OH	★★★☆☆	4/5
Crystal Care Center of Franklin Furnace	12.3 mi	Franklin Furnace, OH	★★★★★	5/5
Madison Park Healthcare	13.2 mi	Huntington, WV	★★★★★	5/5
Heritage Center	14.9 mi	Huntington, WV	★☆☆☆☆	1/5
Huntington Health and Rehabilitation Center	15.2 mi	Huntington, WV	★★☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Coal Grove →

Facility data as of CMS processing date 2026-08-01. CCN 366202.

The Care File

Visit checklist — Crystal Care of Coal Grove

813 1/2 Marion Pike, Coal Grove, OH 45638 · 7405320449

Health inspection rating 3/5 · CMS overall 3/5· Fines (3y): $159,708

Most serious findings on record:

▲ Mar 4, 2024 (F-0684, Immediate jeopardy, one-off): The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Questions for the administrator:

☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
☐ "How do you learn about each resident's background and history, and how does that shape their care?"
☐ "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
☐ "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 366202 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)