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Crystal Lake Rehabilitation and Care Center

999 South Main Street, Pascoag, RI 02859 · Providence County · (401) 568-3091

71 certified beds, about 45 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1991

Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
3 of 5
Quality measures
3 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 415099 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on April 17, 2025, inspectors cited 6 health deficiencies (the Rhode Island average is 9.3, the national average 9.2).

Of 59 health citations since July 2023, 8 were rated as actual harm or immediate jeopardy to residents (5 immediate jeopardy).

CMS lists 15 fines totaling $306,656 in the last three years; the largest was $105,651, and the latest is dated September 25, 2024.

Nurses and nurse aides worked 3.58 hours per resident per day, against 3.71 across Rhode Island and 3.86 nationally. Registered nurses accounted for 1.04 of those hours.

57.6% of nursing staff left within the year CMS measured (Rhode Island average 40.6%).

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 59 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
4J
1K
0L
Actual harm
2G
1H
0I
Potential for more than minimal harm
17D
20E
11F
Potential for minimal harm
0A
2B
1C
April 17, 2025Standard inspection · 6 citations
  1. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) May 17, 2025
    Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, relative to the main kitchen.
  2. F
    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.
    F838 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) May 17, 2025
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies which must be reviewed and updated as necessary, and at least annually.
  3. E
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 17, 2025
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the Minimum Data Set (MDS) Assessment accurately reflected the resident's status for 2 of 2 residents reviewed for smoking, Resident ID #s 10 and 42, and 3 of 3 residents reviewed for restraints, Resident ID #s 9, 10, and 31.
  4. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 17, 2025
    Inspectors wroteBased on record review, resident and staff interview, it has been determined that the facility failed to ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 2 residents reviewed for appointments, Resident ID #25.
  5. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 17, 2025
    Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to insulin administration for 1 of 3 residents reviewed, Resident ID #42.
  6. B
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    F582 · Resident Rights · No actual harm, potential for minimal harm, pattern · Corrected (the home has a date of correction) May 17, 2025
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to properly provide notice to residents and/or representatives informing them of when changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan related to the Skilled Nursing Facility Notice of Medicare Non-Coverage (NOMNC), in a timely manner for 3 of 4 residents reviewed who were discharged from a Medicare covered Part A stay with benefit days remaining, Resident ID #s 353, 354, and 355.
November 6, 2024Complaint inspection · 3 citations
  1. F
    Employ staff that are licensed, certified, or registered in accordance with state laws.
    F839 · Administration · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) November 20, 2024
    Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that staff are licensed, certified, or registered in accordance with applicable State laws for 1 of 1 staff reviewed, Staff A.
  2. E
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) November 20, 2024
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physician's orders for 8 of 8 residents reviewed relative to failing to check blood sugars as ordered, Resident ID #s 1, 4, 6, 7, 8, 9, 10, and 11.
  3. E
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) November 20, 2024
    Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to keep all residents free from significant medication errors for 5 of 6 residents reviewed relative to failing to administer insulin as ordered, Resident ID #s 1, 4, 5, 6 and 7.
September 25, 2024Complaint inspection · 1 citation
  1. G
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 7, 2024
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 2 residents reviewed for the transcription of admissions orders, Resident ID #1.
June 13, 2024Complaint inspection · 1 citation
  1. J
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 27, 2024
    Inspectors wroteBased on record review, witness, resident, and staff interviews, it has been determined that the facility failed to ensure that residents receive adequate supervision to prevent an accident for 1 of 3 residents reviewed for elopement, Resident ID #1.
May 8, 2024Standard inspection · 22 citations
  1. K
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    F805 · Nutrition and Dietary · Immediate jeopardy to resident health or safety, pattern · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide food prepared in a form designed to meet individual needs for 2 of 2 residents reviewed for pudding thick liquids (thickest of fluid consistency to resemble pudding), Resident ID #s 19 and 16 and 2 of 3 residents reviewed for nectar thick liquids (thicker than water, falls slowly from a spoon), Resident ID #s 12, and 100.
  2. H
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · Actual harm, pattern · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, for 2 of 2 residents reviewed for the utilization of the facility bowel protocol, Resident ID #s 47 and 39, and 1 of 1 resident reviewed for wound care observation, Resident ID #4.
  3. F
    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.
    F809 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on record review, resident and staff interview, it has been determined that the facility failed to ensure nourishing snacks were offered to residents who desired them outside of scheduled meal service times for 5 of 5 residents reviewed for bedtime snacks, Resident ID #s 3, 7, 14, 21, and 99.
  4. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store food in accordance with professional standards of food service safety relative to the main kitchen and kitchenette.
  5. F
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    F835 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on record review, surveyor observation, and staff interview it has been determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 2 of 2 residents reviewed requiring pudding thick liquids, Resident ID #s 19 and 16 , for 40 of 48 residents reviewed relative to medication administration, Resident ID #s 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 21, 22, 23, 24, 25, 26, 27, 28, 30, 31, 32, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43, 44, 99, 100, and 199, and for 1 of 1 resident reviewed for foley catheter (a flexible tube inserted into the bladder in order to drain urine) care, Resident ID #33.
  6. F
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections relative to the disinfection of glucometers (a device used to monitor blood glucose). Additionally, the facility failed to ensure that staff utilized Personal Protective Equipment (PPE) properly for 2 of 2 residents reviewed relative to foley catheter (a device that drains urine from your bladder into a collection bag) care and multi drug resistant organism (MDRO), Resident ID #2 and #33.
  7. F
    Implement a program that monitors antibiotic use.
    F881 · Infection Control · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 3 of 3 residents reviewed for antibiotic use, Resident ID #s 26, 29, and 39.
  8. F
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    F947 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide a minimum of 12 hours per year of in-service training to ensure the continuing competence of nurse aides for 3 of 3 Nurse Aides (NA) reviewed, Staff H, I and J.
  9. E
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the assessment accurately reflected the resident's status for 1 of 1 resident assessed for falls, with major injury, Resident ID #19.
  10. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review, and staff interview it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 11 resident's reviewed, Resident ID #s 4, 29, and 100.
  11. E
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 3 of 3 residents reviewed diagnosed with urinary tract infections (UTI), Residents ID #s 26, 29, and 39.
  12. E
    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.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that nursing staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being of each resident, as determined by resident assessments and individual plans of care for 3 of 3 nurses reviewed, Staff E, R, and S and for 3 of 3 Nursing Assistants (NA's) reviewed, Staff H, I, and J.
  13. E
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    F740 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being, for 1 of 1 resident reviewed for initial psychiatric evaluation, Resident ID #39.
  14. E
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 35 opportunities for error observed during the medication administration task, there were 10 errors resulting in an error rate of 28.57%, involving Resident ID #s 19, 20, 29, 45, and 99.
  15. E
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review, and staff interview it has been determined that the facility failed to keep residents free from significant medication errors for 40 of 48 residents reviewed for medication administration, Resident ID #s 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 21, 22, 23, 24, 25, 26, 27, 28, 30, 31, 32, 33, 34, 36, 37, 38, 39, 40, 41, 42, 43, 44, 99, 100, and 199.
  16. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review, and staff interview it has been determined that the facility failed to treat each resident with respect and dignity in an environment that promotes maintenance of his or her quality of life for 1 of 1 resident reviewed relative to foley catheter (a tube that is placed in the body to drain and collect urine from the bladder) care, Resident ID #33.
  17. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following a physician's order for 1 of 1 resident reviewed for double portions, Resident ID #7.
  18. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 resident reviewed for pressure ulcers, Resident ID #2.
  19. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 5 residents reviewed for oxygen use, Resident ID #s 1 and 29, and 1 of 1 resident reviewed for suctioning, Resident ID #19.
  20. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 1 of 2 nursing carts and 1 of 1 medication room observed.
  21. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are accurately documented for 1 of 1 resident reviewed relative to lung sound documentation and suctioning, Resident #19.
  22. C
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    F577 · Resident Rights · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on record review, staff and resident interview, it has been determined that the facility failed to update the results of the most recent surveys of the facility conducted by Federal or State Surveyors, or post the survey results in a readily accessible area for the residents, staff, and general public.
April 4, 2024Complaint inspection · 3 citations
  1. J
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 19, 2024
    Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that residents receive adequate supervision to prevent an elopement for 1 of 1 resident reviewed who successfully eloped, Resident ID #1.
  2. E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) April 19, 2024
    Inspectors wroteBased on record review, staff, and resident representative interview, it has been determined that the facility failed to protect and promote the rights of the resident for 5 of 5 residents reviewed who had their picture posted on social media, Resident ID #s 5,6, 7, 8, and 9.
  3. E
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    F676 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) April 19, 2024
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living (ADL) for 5 of 5 residents reviewed who are not independent with transfers and/or ambulation, Resident ID #s 1, 2, 3, 4, and 5.
March 28, 2024Complaint inspection · 1 citation
  1. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 29, 2024
    Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 2 new admissions reviewed, Resident ID #4.
March 22, 2024Complaint inspection · 1 citation
  1. E
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) April 19, 2024
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services relative to Urinary Tract Infections (UTI) and/or Indwelling catheters (a flexible tube that collects urine from the bladder and leads to a drainage bag), for 3 of 3 residents reviewed, Resident ID #s 1, 2 and 4.
February 29, 2024Complaint inspection · 4 citations
  1. F
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    F835 · Administration · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) March 19, 2024
    Inspectors wroteBased on record review and resident and staff interview, it has been determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 3 residents reviewed, Resident ID #1.
  2. E
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) March 19, 2024
    Inspectors wroteBased on record review, staff, and resident interview, it has been determined that the facility failed to ensure that resident's receive treatment and care in accordance with professional standards of practice, for 1 of 1 resident reviewed for an ordered dermatology consult, Resident ID #1.
  3. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 19, 2024
    Inspectors wroteBased on record review, staff and resident interview, it has been determined that the facility failed to treat each resident with respect and dignity in an environment that promotes maintenance of his or her quality of life for 1 of 3 residents reviewed, Resident ID #1.
  4. D
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 19, 2024
    Inspectors wroteBased on record review, staff, and resident interview it has been determined that the facility failed to respect the residents right to personal privacy for 1 of 2 residents reviewed who receive mail at the facility, Resident ID #1.
February 27, 2024Complaint inspection · 4 citations
  1. G
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 19, 2024
    Inspectors wroteBased on record review, staff and resident interview, it has been determined that the facility failed to provide reasonable accommodation of resident needs and preferences, relative to individualizing the physical environment relative to the resident's bedroom and bathroom [ROOM NUMBER] of 1 resident reviewed, Resident ID # 1, who is visually impaired.
  2. D
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 19, 2024
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide written notice of the facility's bed-hold policy to the resident or resident representative, prior to the transfer of the resident to the hospital, for 1 of 1 resident reviewed, Resident ID #1.
  3. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 19, 2024
    Inspectors wroteBased on record review, staff and resident interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed for falls, Resident ID #1.
  4. B
    Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
    F573 · Resident Rights · No actual harm, potential for minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) March 19, 2024
    Inspectors wroteReview of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities last revised 2/3/2023 states in part, The facility must provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically), or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays) .The facility must allow the resident to obtain a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and 2 working days advance notice to the [...]
January 10, 2024Complaint inspection · 1 citation
  1. E
    Honor the resident's right to manage his or her financial affairs.
    F567 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 23, 2024
    Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to assure residents who have authorized the facility in writing to manage any personal funds have ready and reasonable access to those funds, relative to petty cash.
December 7, 2023Complaint inspection · 4 citations
  1. J
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 6, 2024
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to protect a resident's right to be free from sexual abuse for 1 of 5 residents reviewed, Resident ID #1.
  2. J
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    F740 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 6, 2024
    Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and that his/her care plan is reviewed and revised accordingly for 1 of 2 residents reviewed, Resident ID #2.
  3. E
    Provide activities to meet all resident's needs.
    F679 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 6, 2024
    Inspectors wroteBased on surveyor observation, record review and staff interview it has been determined that the facility failed to provide an ongoing program which includes group activities and/or one-on-one visits (1:1), on 1 of 4 units reviewed for activities for residents with cognitive impairment that resided on the Subacute Unit, including those residents that were admitted on the unit and recently discharged , Resident ID #s 1, 2, 3, 4 and 5.
  4. E
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    F940 · Administration · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 6, 2024
    Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to develop, implement, and maintain an effective training program for all newly hired employees, consistent with their expected roles, relative to orientation education involving abuse, dementia and behavioral health management per the facility assessment, for 4 of 5 newly hired employees, Staff G, H, I, and J.
September 12, 2023Complaint inspection · 1 citation
  1. E
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) October 12, 2023
    Inspectors wroteBased on record review and staff and resident interview, it has been determined that the facility failed to ensure residents are free from neglect for 11 of 14 residents reviewed, Resident ID #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11.
July 14, 2023Standard inspection · 7 citations
  1. F
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) August 13, 2023
    Inspectors wroteBased on surveyor observations, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 2 of 2 medication storage rooms.
  2. E
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 13, 2023
    Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 1 of 1 resident reviewed related to an as needed blood pressure medication, Resident ID #20.
  3. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2023
    Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life relative to assistance with eating during meals, for 1 of 3 residents reviewed, Resident ID #34.
  4. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2023
    Inspectors wroteBased on surveyor observations, record review, and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of quality relative to following a physician's order for a fluid restriction for 1 of 1 resident reviewed, Resident ID #213.
  5. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2023
    Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed relative to the failure to administer an as needed blood pressure medication, Resident ID #20.
  6. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2023
    Inspectors wroteBased on surveyor observations, record review, and staff interview, it has been determined that the facility failed to ensure that a residents environment remains as free from accident hazards as possible for 1 of 1 resident reviewed, Resident ID #34.
  7. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2023
    Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections relative to following contact precautions for 1 of 2 residents reviewed, Resident ID #47.

Fire safety inspections

9 fire safety citations on file: 2 on April 17, 2025, 6 on May 8, 2024, 1 on July 14, 2023.

Every fire safety citation9 citations
  1. F
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · April 17, 2025 · Corrected (the home has a date of correction)
  2. F
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · April 17, 2025 · Corrected (the home has a date of correction)
  3. F
    Establish emergency prep training and testing.
    E 36 · May 8, 2024 · Corrected (the home has a date of correction)
  4. F
    Install an approved automatic sprinkler system.
    K 351 · May 8, 2024 · Corrected (the home has a date of correction)
  5. F
    Have simulated fire drills held at unexpected times.
    K 712 · May 8, 2024 · Corrected (the home has a date of correction)
  6. F
    Have restrictions on the use of portable space heaters.
    K 781 · May 8, 2024 · Corrected (the home has a date of correction)
  7. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · May 8, 2024 · Corrected (the home has a date of correction)
  8. F
    Have proper medical gas storage and administration areas.
    K 923 · May 8, 2024 · Corrected (the home has a date of correction)
  9. D
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · July 14, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
September 25, 2024Fine $29,328
June 13, 2024Fine $27,213
February 27, 2024Fine $9,318
February 27, 2024Fine $10,845
February 27, 2024Fine $105,651
February 27, 2024Payment Denial 2 days from May 27, 2024
February 20, 2024Fine $4,938
February 12, 2024Fine $4,938
January 22, 2024Fine $14,814
January 8, 2024Fine $4,938
January 2, 2024Fine $4,545
December 11, 2023Fine $13,762
December 7, 2023Fine $53,430
December 7, 2023Payment Denial 8 days from December 29, 2023
November 20, 2023Fine $4,587
November 13, 2023Fine $4,587
October 23, 2023Fine $13,762

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeRhode IslandUnited States
All nursing staff (RN, LPN and aides)3.583.713.86
Registered nurses1.040.770.69
All nursing staff on weekends3.133.343.42
Nurse aides2.23
Licensed practical nurses0.31
Nursing staff turnover (share who left in a year)57.6%40.6%45.8%
Registered nurse turnover57.1%37.9%42.9%
Administrators who left1

CMS expects 3.91 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.76 on weekdays and 3.13 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 11.4% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.74 in April to June 2025 to 3.58 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.581.043.763.13 11.4%0 of 9045
Oct to Dec 20253.580.923.773.10 7.1%0 of 9241
Jul to Sep 20253.800.963.963.38 11.8%0 of 9245
Apr to Jun 20253.740.883.913.31 21.7%0 of 9147
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Rhode Island, Jan to Mar 20263.670.693.823.305.4%1% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.

Official wage estimates for Rhode Island

JobMedianMiddle halfEmployed
Rhode Island, all employers
CNAs (nursing assistants)$22.33$21.52 to $22.8210,220
LPNs and LVNs$38.51$37.45 to $39.021,290
Registered nurses$48.39$39.35 to $51.4910,090
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeRhode IslandUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
26.519.613.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.50.80.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
6.22.51.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
1.23.63.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
3.82.01.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
21.416.814.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
3.54.24.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
35.722.515.4
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
0.71.61.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
2.61.71.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Crystal Lake Rehabilitation and Care Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (46.8% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

46.8% this home

No different from the national rate

US median of homes 51.5% · Rhode Island: 24 better, 1 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 31 eligible stays.

Potentially preventable readmissions

9.7% this home

No different from the national rate

US median of homes 10.7% · Rhode Island: 0 better, 0 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 38 eligible stays.

Infections that led to a hospital stay

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

US median of homes 7.1% · Rhode Island: 0 better, 0 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 14 eligible stays.

Self-care and mobility at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Rhode Island59.1% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 6 residents counted.

Falls with major injury

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Rhode Island0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 7 residents counted.

New or worsened pressure ulcers

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Rhode Island2.6% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 7 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Rhode Island100.0% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 3 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: CL OPERATING LLC.

NameRoleTypeShareSince
Fink, Boruch5% or greater direct ownership interestIndividual5%04/01/2019
Leifer, Joel5% or greater direct ownership interestIndividual48%04/01/2019
Oberlander, David5% or greater direct ownership interestIndividual48%04/01/2019
Hermann, EdwardW-2 managing employeeIndividual04/01/2019
Stern, SamuelCorporate officerIndividual04/01/2019

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 16 problems in this area, most recently on April 17, 2025: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 11 problems in this area, most recently on April 17, 2025: "Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered."
  3. When is the care plan meeting, and can family attend it?Inspectors cited 9 problems in this area, most recently on April 17, 2025: "Ensure each resident receives an accurate assessment."
  4. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 7 problems in this area, most recently on November 6, 2024: "Ensure that residents are free from significant medication errors."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.13 hours per resident per day, below the Rhode Island average of 3.34.
  6. How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

Other nursing homes nearby

Rhode Island contacts for a concern about a nursing home

These are the official offices in Rhode Island. NursingHomeClear cannot take or act on complaints.

Common questions

What is Crystal Lake Rehabilitation and Care Center's Medicare star rating?
CMS rates Crystal Lake Rehabilitation and Care Center 1 out of 5 stars overall, with 1 for health inspections, 3 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Crystal Lake Rehabilitation and Care Center get at its last inspection?
6 health deficiencies at the standard inspection on April 17, 2025. The Rhode Island average is 9.3.
Has Crystal Lake Rehabilitation and Care Center been fined?
Yes. CMS lists 15 fines totaling $306,656 in the last three years.
Does Crystal Lake Rehabilitation and Care Center accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Crystal Lake Rehabilitation and Care Center?
CMS lists 5 owners and managers. Legal business name: CL OPERATING LLC.

Sources

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