Home / Illinois / Crystal Lake
Crystal Pines Rehab & HCC
335 North Illinois Avenue, Crystal Lake, IL 60014 · Mc Henry County · (815) 459-7791
110 certified beds, about 83 residents a day · For profit - Corporation · Medicare and Medicaid since 1973
CMS abuse icon: cited for abuse in a recent inspection Last standard inspection more than 2 years ago Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
2 of 5
Staffing
1 of 5
Quality measures
2 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 145257 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on June 5, 2024, inspectors cited 11 health deficiencies (the Illinois average is 12.6, the national average 9.2).
Of 48 health citations since August 2022, 7 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 4 fines totaling $130,776 in the last three years; the largest was $83,990, and the latest is dated May 6, 2026.
Nurses and nurse aides worked 3.15 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 0.83 of those hours.
55.7% of nursing staff left within the year CMS measured (Illinois average 44.5%).
CMS links it to Tutera Senior Living & Health Care, an affiliated group of 25 nursing homes.
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.
808/22
907/23
103/24
1106/24
107/24
211/24
111/24
112/24
201/25
102/25
304/25
104/25
108/25
110/25
111/25
112/25
104/26
105/26
106/26
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 48 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
6G
0H
0I
Potential for more than minimal harm
27D
5E
9F
Potential for minimal harm
0A
0B
0C
June 11, 2026Complaint inspection · 1 citation
- D Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from misappropriation of property for 1 of 3 residents (R1) reviewed for abuse in the sample of 3. This past non-compliance occurred from 5/11/26 to 6/10/26.
May 6, 2026Complaint inspection · 1 citation
- G Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on interview and record review the facility failed to ensure an enteral feeding was administered as ordered 1 of 3 residents (R1) reviewed for enteral feedings in the sample of 3. This failure resulted in R1's admission to the acute care hospital for treatment of aspiration pneumonia.
April 20, 2026Complaint inspection · 1 citation
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to safely transport a resident. This failure resulted in R1 falling from her wheelchair during the transport and sustaining a 5 centimeter (cm.) laceration to her forehead requiring emergency medical attention, 11 sutures and hospitalization. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 4. This past noncompliance occured from 3/16/26 to 3/23/26.
December 3, 2025Complaint inspection · 1 citation
- D Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation and interview the facility failed to ensure residents are treated with dignity and respect. This applies to 2 of 4 residents (R1, R2) reviewed for resident rights in the sample of 4.
November 21, 2025Complaint inspection · 1 citation
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's safety during an outdoor activity. This applies to 1 of 3 residents (R2) reviewed for safety and supervision in the sample of 5.
October 14, 2025Complaint inspection · 1 citation
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to ensure a residents bed was maintained to ensure no hazards were present for one of three residents (R1) reviewed for injury in the sample of three. This failure resulted in R1 experiencing a large skin tear from exposed sharp metal on the bed, requiring R1 being sent to the local hospital and requiring 12 sutures to the wound.
August 20, 2025Complaint inspection · 1 citation
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review the facility failed to ensure a resident remained free of sexual abuse. This applies to one of three residents (R5) in the sample of eight reviewed for abuse.
April 29, 2025Complaint inspection · 1 citation
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review the facility failed to perform thorough pressure ulcer assessments and initiate a baseline care plan for a resident admitted to the facility with a pressure ulcer for 1 of 1 residents (R1) reviewed for pressure ulcers in the sample of 4.
April 15, 2025Complaint inspection · 3 citations
- F Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dietary staff are properly trained. This has the potential to affect all 73 residents in the facility.
- F Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure correct food service scoops were used to serve mashed potatoes. This has the potential to affect all 73 residents in the facility.
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure employees practiced safe food handling practices resulting in risks of cross-contamination. This has the potential to affect all 73 residents in the facility.
February 24, 2025Complaint inspection · 1 citation
- D Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview, and record review the facility failed to ensure a resident was free from misappropriation. This applies to 1 of 4 residents (R1) reviewed for misappropriation in the sample of 4.
January 8, 2025Complaint inspection · 2 citations
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure care was provided to a resident in a dignified manner for 1 of 3 residents (R3) reviewed for resident rights in the sample of 6.
- D Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's was free of misappropriation for 1 of 3 residents (R2) reviewed for abuse in the sample of 6.
December 11, 2024Complaint inspection · 1 citation
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's urinary catheter was changed when is was dirty and clogged. The facility failed to keep the catheter drainage bag below the level of the bladder and off the bed for 2 of 3 residents (R1, R3) reviewed for catheters in the sample of 3.
November 27, 2024Complaint inspection · 1 citation
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive care plan that provided interventions for a resident's known behaviors for 1 of 9 residents (R2) reviewed for Care Plans in the sample of 9.
November 14, 2024Complaint inspection · 2 citations
- J Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 of 4 residents (R8) was free from verbal and mental abuse when a staff member repeatedly told R8 that his genitalia was tiny and escalated to saying R8's genitalia is useless and should just be cut off. This verbal assault resulted in R8 feeling very hurt, angry, feeling pain, and significant distress from the verbal abuse. This failure applies to 1 of 4 residents (R8) reviewed for mental abuse in the sample of 14. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/7/24 when R8 notified V2 (Director of Nursing) and V1 (Administrator) that V10 (Certified Nursing Assistant- CNA) repeatedly told R8 that his genitalia was tiny and escalated to V10 saying R8's genitalia is useless and should just be cut off. [...]
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review the facility failed to immediately report staff to resident verbal and mental abuse to the Administrator and local law enforcement for 1 of 4 residents (R8) reviewed for abuse in the sample of 9.
July 18, 2024Complaint inspection · 1 citation
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review the facility failed to ensure an alleged physical abuse was immediately reported to the administrator for 1 of 4 residents (R1) reviewed for allegations of abuse in the sample of 4.
June 5, 2024Standard inspection · 11 citations
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who is a high risk for falls was supervised and ensure fall interventions were in place. This failure resulted in R6 falling forward out of her wheelchair and hitting her head on the floor. R6 sustained a forehead laceration requiring transport to the hospital and R6 requiring sutures. This applies to 1 of 18 residents (R6) reviewed for safety in the sample of 18.
- E Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents oxygen equipment was changed and labeled for 4 of 9 residents (R4, R14, R24, R34) reviewed for oxygen use in the sample of 18.
- E Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review the facility to administer medications at the prescribed time. This applies to 4 of 18 residents (R47, R70, R28, R30) in sample of 18 reviewed for medication administration.
- E Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food to meet residents' needs for four of 18 residents (R28, R29, R3, R8) reviewed for food in the sample of 18. 1. R28's admission Record dated June 5, 2024 shows she was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to embolism of unspecified cerebral artery. R28's Order Summary Report dated June 5, 2024 shows an order for regular texture diet, no cranberry juice, and no green leafy vegetables. R28's order summary report shows that R28 is on coumadin (blood thinner). On June 4, 2024 at 10:15 AM, during resident council meeting, R28 said that she is not supposed to eat green leafy vegetables because she is on coumadin. R28 said the green leafy vegetables thickens her blood. R28 said she gets green leafy vegetables frequently. [...]
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure the prescribed treatment was applied to a resident with Moisture Associated Skin Damage. This applies to 1 of 18 residents (R13) reviewed for quality of care in the sample of 18.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident with a history of pressure injuries for 1 of 4 residents (R75) reviewed for pressure in the sample of 18.
- D Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review the facility failed to assess and implement interventions for a resident with contractures for 1 of 7 residents (R75) reviewed for range of motion in the sample of 18.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a urinary catheter urine collection bag was positioned off the floor to prevent cross-contamination for 1 of 10 residents (R24) reviewed for urinary catheters in the sample of 18.
- D Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure R75's enteral nutrition bag was labeled for 1 of 4 residents (R75) reviewed for enteral feedings in the sample of 18.
- D Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for three of 18 residents (R70, R28, R30) reviewed for medications in the sample of 18.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff donned all applicable Personal Protective Equipment while providing direct care to a resident with Enhanced Barrier Precautions. This applies to 1 of 18 residents (R13) reviewed for infection control in the sample of 18.
March 26, 2024Complaint inspection · 1 citation
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to supervise a resident in the shower room for one of one resident (R1) reviewed for safety in the sample of 3. This past non-compliance occurred from March 3, 2024 to March 9, 2024.
July 19, 2023Standard inspection · 9 citations
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to ensure a resident was safely assisted to re-position in bed. This failure contributed to (R17) sustaining abrasions to her toes which became gangrene requiring wound care, hospitalization, and recommended amputation to her right toes. This applies to 1 of 7 residents reviewed for safety in the sample of 17.
- G Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview and record review the facility failed to ensure monthly dietary assessments were completed for a resident on a feeding tube (R55) and for a resident with non- pressure wounds with a history of significant weight loss (R17) and failed to notify the Dietician of continued significant weight loss for a resident (R17). These failures contributed to a delay in implementing additional dietary interventions for R17 following a significant weight loss of 9.09% in 2 months. This applies to 2 of 12 residents (R17, R55) reviewed for weight loss in the sample of 17.
- F Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on observation, interview, and record review the facility failed to employ a qualified Food Service Director. This applies to all 67 residents in the facility.
- F Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview, and record review the facility failed to serve the menu as written. This applies to all 67 residents in the facility.
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed to wash, handle, and store food service utensils in a sanitary manner. This applies to all 67 residents in the facility.
- F Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure Enhanced Barrier Precautions were implemented and failed to develop Enhanced Barrier Precautions Policy and Procedures.
- E Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Inspectors wroteBased on observation, interview, and record review the facility failed to use the correct serving utensils for mechanical soft and puree residents. This applies to 14 of 14 residents (R2, R8, R10, R11, R15, R22, R23, R25, R29, R32, R41, R47, R51, and R55) reviewed for mechanically altered diets in the sample of 17.
- D Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident rooms were maintained in a homelike environment for 2 of 17 residents (R28 and R48) reviewed for homelike environment in the sample of 17.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation interview and record review the facility failed to administer prescribed medications and failed to ensure medications were not left at bedside to 2 of 5 residents (R7, R116) in the sample of 17. 1. R116's Physician Order Sheet dated 7/2023 show R116 has an order of Sodium Bicarbonate Oral Tablet 650 mg (milligrams) BID (two times per day) for gastroesophageal reflux disease. On [DATE] at 8:30 AM, R116 was sitting in his room, R116 said he does not get all his medications and his daughter was handling this. On [DATE] at 1:17 PM, V7 (R116's daughter) said R116 was admitted to the facility with orders of Sodium Bicarbonate. V7 said R116 has been on this medication for a long time. V7 said R116 did not get this medication for at least two days. R116's progress notes dated [DATE] timed at 11:26 PM show, Sodium Bicarbonate is not available in the facility. [...]
August 24, 2022Standard inspection · 8 citations
- F Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure there was adequate staffing in the kitchen. This failure has the potential to effect all 68 residents receiving food from the kitchen.
- F Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was served at a palatable temperature. This failure has the potential to affect all 68 residents receiving food from the kitchen.
- E 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.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure meals were served according to normal mealtimes in the community. This applies to 4 of 18 residents (R7, R11, R54, R60) reviewed for mealtimes in the sample of 18.
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review the facility failed to ensure a resident was treated in a dignified manner by all staff. This applies to 1 of 18 residents (R7) reviewed for dignity in a sample of 18.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a suprapubic catheter was changed for a resident with a history of a urinary tract infection for 1 of 7 residents (R42) reviewed for catheter care in the sample of 18.
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure a dietitian's recommendations were reviewed with a physician for residents with significant weight loss, failed to notify a dietitian of significant weight loss and failed to implement the dietitian's recommendations for a resident with significant weight loss. This applies to 2 of 6 residents (R39 and R51) reviewed for weight loss in the sample of 18.
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered. There were 26 opportunities with 3 errors resulting in an 11.54 % error rate. This applies to 2 of 3 residents (R24 and R116) observed during medication pass.
- D Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was prepared in a sanitary manner to prevent cross contamination for 1 of 18 residents (R8) reviewed for food preparation in the sample of 18.
Fire safety inspections
33 fire safety citations on file: 15 on June 5, 2024, 11 on July 19, 2023, 7 on August 24, 2022.
Every fire safety citation33 citations
- F Address subsistence needs for staff and patients.
- F Establish policies and procedures for sheltering.
- F Implement emergency and standby power systems.
- F Install emergency lighting that can last at least 1 1/2 hours.
- F Have properly located and lighted "Exit" signs.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Install an approved automatic sprinkler system.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- E Provide properly protected cooking facilities.
- E Properly select, install, inspect, or maintain portable fire extinguishes.
- E Install corridor and hallway doors that block smoke.
- E Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E Ensure proper usage of power strips and extension cords.
- E Have proper medical gas storage and administration areas.
- F Conduct testing and exercise requirements.
- F Install emergency lighting that can last at least 1 1/2 hours.
- F Have properly located and lighted "Exit" signs.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Provide properly protected cooking facilities.
- E Install corridor and hallway doors that block smoke.
- E Have properly installed electrical wiring and gas equipment.
- E Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
- E Ensure proper usage of power strips and extension cords.
- F Establish staff and initial training requirements.
- F Install emergency lighting that can last at least 1 1/2 hours.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Have properly installed electrical wiring and gas equipment.
- E Have exits that are accessible at all times.
- E Provide properly protected cooking facilities.
- E Ensure proper usage of power strips and extension cords.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| May 6, 2026 | Fine | $83,990 |
| April 20, 2026 | Fine | $15,935 |
| November 14, 2024 | Fine | $16,801 |
| June 5, 2024 | Fine | $14,050 |
| June 5, 2024 | Payment Denial | 31 days from July 5, 2024 |
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.
| Measure | This home | Illinois | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.15 | 3.45 | 3.86 |
| Registered nurses | 0.83 | 0.72 | 0.69 |
| All nursing staff on weekends | 2.98 | 3.07 | 3.42 |
| Nurse aides | 1.87 | ||
| Licensed practical nurses | 0.45 | ||
| Nursing staff turnover (share who left in a year) | 55.7% | 44.5% | 45.8% |
| Registered nurse turnover | 47.1% | 41.8% | 42.9% |
| Administrators who left | 2 |
CMS expects 4.65 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 3.22 on weekdays and 2.98 on weekends, 7% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.1% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.42 in April to June 2025 to 3.15 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.15 | 0.83 | 3.22 | 2.98 | 0.1% | 0 of 90 | 83 |
| Oct to Dec 2025 | 3.15 | 0.78 | 3.23 | 2.94 | 9.4% | 0 of 92 | 81 |
| Jul to Sep 2025 | 3.29 | 0.80 | 3.39 | 3.02 | 9.3% | 0 of 92 | 77 |
| Apr to Jun 2025 | 3.42 | 0.87 | 3.56 | 3.06 | 10.2% | 0 of 91 | 74 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Illinois, Jan to Mar 2026 | 3.26 | 0.65 | 3.40 | 2.92 | 5.4% | 0.6% 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.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Illinois | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 24.2 | 13.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.0 | 0.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.8 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.8 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.7 | 2.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 28.2 | 14.3 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.1 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 18.5 | 21.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 26.8 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 2.3 | 13.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.6 | 2.0 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.7 | 2.2 | 1.8 |
Owners and operators
Legal business name: CRYSTAL PINES REHABILITATION AND HEALTH CARE CENTER, LLC. CMS links this home to Tutera Senior Living & Health Care, a group of 25 nursing homes averaging 2.1 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Jct Investments, LLC | Direct ownership interest | Organization | 12/28/2021 | |
| Tutera Investments, LLC | Direct ownership interest | Organization | 12/28/2021 | |
| Joseph Charles Tutera 2013 Family Irrevociable Trust Agreement | Indirect ownership interest | Organization | 12/31/2023 | |
| Marian Olander Tutera 2020 Mrtl Tr | Indirect ownership interest | Organization | 12/31/2023 | |
| Tutera, Joseph | Indirect ownership interest | Individual | 12/31/2023 | |
| Tutera, Marian | Indirect ownership interest | Individual | 12/31/2023 | |
| Bloom, Randall | Corporate officer | Individual | 12/28/2021 | |
| Brooks, Kiley | Corporate officer | Individual | 12/28/2021 | |
| Walnut Creek Management Company LLC | Operational/managerial control | Organization | 01/01/2017 | |
| Bloom, Randall | Operational/managerial control | Individual | 12/28/2021 | |
| Brooks, Kiley | Operational/managerial control | Individual | 12/28/2021 | |
| Elmahboub, Asim | Operational/managerial control | Individual | 05/01/2025 | |
| Morton, Scott | Operational/managerial control | Individual | 05/01/2025 | |
| Tutera, Joseph | Operational/managerial control | Individual | 12/28/2021 | |
| Flanagan, Michael | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 05/21/2025 | |
| Ti-Crystal Lake, LLC | Adp of the SNF | Organization | 12/28/2021 | |
| Walnut Creek Management Company LLC | Adp of the SNF | Organization | 12/28/2021 | |
| Bloom, Randall | Adp of the SNF | Individual | 12/28/2021 | |
| Brooks, Kiley | Adp of the SNF | Individual | 12/28/2021 | |
| Elmahboub, Asim | Adp of the SNF | Individual | 05/01/2025 | |
| Fraase, Jennifer | Adp of the SNF | Individual | 05/01/2025 | |
| Morton, Scott | Adp of the SNF | Individual | 05/01/2025 | |
| Tutera, Joseph | Adp of the SNF | Individual | 12/28/2021 |
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.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 18 problems in this area, most recently on May 6, 2026: "Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 12 problems in this area, most recently on April 15, 2025: "Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 7 problems in this area, most recently on June 11, 2026: "Protect each resident from the wrongful use of the resident's belongings or money."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 4 problems in this area, most recently on December 3, 2025: "Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.98 hours per resident per day, below the Illinois average of 3.07.
- How long has the current administrator been here?CMS counts 2 administrators who left in the period it measured.
Other nursing homes nearby
- Fair Oaks Health Care Center Crystal Lake, 1.8 mi · 3 of 5 stars · 29 citations
- Pearl of Crystal Lake, the Crystal Lake, 5 mi · 5 of 5 stars · 31 citations
- Alden Estates Cts of Huntley Huntley, 6.8 mi · 2 of 5 stars · 30 citations
- La Bella of Woodstock Woodstock, 7 mi · 1 of 5 stars · 91 citations
- Ignite Medical McHenry McHenry, 7.3 mi · 3 of 5 stars · 40 citations
- Alden Terrace of McHenry Rehab McHenry, 8.4 mi · 1 of 5 stars · 50 citations
- Avondale Estates of Elgin Elgin, 10.7 mi · 5 of 5 stars · 11 citations
- Alta Rehab at Wauconda Wauconda, 11.4 mi · 5 of 5 stars · 26 citations
Illinois contacts for a concern about a nursing home
These are the official offices in Illinois. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Illinois Department of Public Health, Nursing Homes, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Illinois Long-Term Care Ombudsman Program, Illinois Department on Aging, 1-800-252-8966. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: IDPH Quarterly Reports of Nursing Home Violators, where Illinois publishes its own records on licensed homes.
Common questions
- What is Crystal Pines Rehab & HCC's Medicare star rating?
- CMS rates Crystal Pines Rehab & HCC 1 out of 5 stars overall, with 2 for health inspections, 1 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Crystal Pines Rehab & HCC get at its last inspection?
- 11 health deficiencies at the standard inspection on June 5, 2024. The Illinois average is 12.6.
- Has Crystal Pines Rehab & HCC been fined?
- Yes. CMS lists 4 fines totaling $130,776 in the last three years.
- Does Crystal Pines Rehab & HCC 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 Pines Rehab & HCC?
- CMS lists 23 owners and managers, and links the home to Tutera Senior Living & Health Care. Legal business name: CRYSTAL PINES REHABILITATION AND HEALTH CARE CENTER, LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.