ElderGrade

Inspection citations at Crystal Lake Rehabilitation And Care Center

60 citations on record, 8 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 6 0
2024 41 6
2023 13 2
B April 17, 2025 Tag F0582 Corrected May 2025

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

No actual harm, minimal potential

D April 17, 2025 Tag F0658 Corrected May 2025

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

E April 17, 2025 Tag F0684 Corrected May 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

E April 17, 2025 Tag F0641 Corrected May 2025

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

F April 17, 2025 Tag F0838 Corrected May 2025

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

No actual harm, potential for more than minimal harm

F April 17, 2025 Tag F0812 Corrected May 2025

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E November 6, 2024 Tag F0760 Complaint investigation Corrected Nov 2024

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

E November 6, 2024 Tag F0658 Complaint investigation Corrected Nov 2024

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

F November 6, 2024 Tag F0839 Complaint investigation Corrected Nov 2024

Administration Deficiencies

Employ staff that are licensed, certified, or registered in accordance with state laws.

No actual harm, potential for more than minimal harm

G September 25, 2024 Tag F0760 Complaint investigation Corrected Oct 2024

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Actual harm to a resident

J June 13, 2024 Tag F0689 Complaint investigation Corrected Jun 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Immediate jeopardy to resident health or safety

C May 8, 2024 Tag F0577 Corrected May 2024

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

No actual harm, minimal potential

D May 8, 2024 Tag F0842 Corrected May 2024

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D May 8, 2024 Tag F0761 Corrected May 2024

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

D May 8, 2024 Tag F0695 Corrected May 2024

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D May 8, 2024 Tag F0686 Corrected May 2024

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D May 8, 2024 Tag F0658 Corrected May 2024

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D May 8, 2024 Tag F0550 Corrected May 2024

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E May 8, 2024 Tag F0760 Corrected May 2024

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

E May 8, 2024 Tag F0759 Corrected May 2024

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

E May 8, 2024 Tag F0740 Corrected May 2024

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

No actual harm, potential for more than minimal harm

E May 8, 2024 Tag F0726 Corrected May 2024

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

No actual harm, potential for more than minimal harm

E May 8, 2024 Tag F0690 Corrected May 2024

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

E May 8, 2024 Tag F0656 Corrected May 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

E May 8, 2024 Tag F0641 Corrected May 2024

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

F May 8, 2024 Tag F0947 Corrected May 2024

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

No actual harm, potential for more than minimal harm

F May 8, 2024 Tag F0881 Corrected May 2024

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

F May 8, 2024 Tag F0880 Corrected May 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

F May 8, 2024 Tag F0835 Corrected May 2024

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

No actual harm, potential for more than minimal harm

F May 8, 2024 Tag F0812 Corrected May 2024

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

F May 8, 2024 Tag F0809 Corrected May 2024

Nutrition and Dietary Deficiencies

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

No actual harm, potential for more than minimal harm

H May 8, 2024 Tag F0684 Corrected May 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Actual harm to a resident

K May 8, 2024 Tag F0805 Corrected May 2024

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Immediate jeopardy to resident health or safety

E April 4, 2024 Tag F0676 Complaint investigation Corrected Apr 2024

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

No actual harm, potential for more than minimal harm

E April 4, 2024 Tag F0550 Complaint investigation Corrected Apr 2024

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

J April 4, 2024 Tag F0689 Complaint investigation Corrected Apr 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Immediate jeopardy to resident health or safety

D March 28, 2024 Tag F0684 Complaint investigation Corrected May 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

E March 22, 2024 Tag F0690 Complaint investigation Corrected Apr 2024

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D February 29, 2024 Tag F0583 Complaint investigation Corrected Mar 2024

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

No actual harm, potential for more than minimal harm

D February 29, 2024 Tag F0550 Complaint investigation Corrected Mar 2024

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.