Inspection Reports for Crystal Lake Rehabilitation and Care Center
999 SOUTH MAIN STREET, RI, 02859
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
112% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
66% occupied
Based on a April 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
May 27, 2025
Visit Reason
An off-site desk audit was conducted on May 27, 2025, to review all previous deficiencies cited on April 17, 2025.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
May 16, 2025
Visit Reason
A revisit survey was conducted on May 16, 2025, to verify correction of all previous deficiencies cited on April 15, 2025, during the Life Safety Code survey.
Findings
All deficiencies cited in the prior Life Safety Code survey have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 47
Capacity: 71
Deficiencies: 7
Apr 17, 2025
Visit Reason
A recertification survey was conducted from 4/14/2025 through 4/17/2025 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities, including State licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to Medicaid/Medicare coverage notices, accuracy of assessments, professional standards of care, food safety, facility assessment, and life safety code compliance. Plans of correction were submitted for all deficiencies with ongoing monitoring and audits planned.
Deficiencies (7)
| Description |
|---|
| Facility failed to properly provide Medicare Non-Coverage Notices (NOMNC) to residents discharged from Medicare covered stays. |
| Facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' status for tobacco use and restraints. |
| Facility failed to meet professional standards of care related to insulin administration for residents with diabetes. |
| Facility failed to ensure residents received necessary care and services to attain or maintain highest practicable physical well-being. |
| Facility failed to maintain food safety standards including cleanliness of ice machine and kitchen appliances. |
| Facility failed to conduct and document a comprehensive facility assessment to determine resources necessary to care for residents. |
| Facility failed to maintain means of egress free of obstructions and failed to ensure fire doors were inspected and tested annually. |
Report Facts
Capacity: 71
Census: 47
Residents reviewed for NOMNC: 3
Residents reviewed for MDS accuracy: 4
Residents reviewed for insulin administration: 3
Residents reviewed for care services: 2
Residents affected by life safety deficiency: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Vaccaro | LNHA | Signed the plan of correction and certification of findings |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 27, 2024
Visit Reason
A revisit survey was conducted on May 29, 2024, for all previous deficiencies cited on the April 30, 2024, Re-certification/Licensure Life Safety Code survey.
Findings
The deficiencies have been corrected and no new noncompliance was identified. The facility is in compliance with all regulations surveyed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric W Kiernan | Surveyor | Named as surveyor conducting the revisit survey |
Inspection Report
Annual Inspection
Census: 48
Capacity: 71
Deficiencies: 7
May 8, 2024
Visit Reason
The inspection was a recertification survey conducted at Crystal Lake Rehabilitation and Care Center to assess compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
The survey identified immediate jeopardy related to food safety and resident care, including failure to treat residents with dignity and respect, inadequate comprehensive care plans, medication errors, quality of care issues, infection control deficiencies, and life safety code violations. The facility was required to implement corrective actions and plans of correction.
Severity Breakdown
Immediate Jeopardy: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Immediate jeopardy identified under 42 CFR 483.80 - Food safety related to preparation of thickened liquids and resident aspiration risk. | Immediate Jeopardy |
| Failure to treat residents with dignity and respect, including failure to protect privacy and maintain resident rights. | Immediate Jeopardy |
| Inadequate comprehensive care plans for multiple residents, including failure to address wounds, falls, and chronic conditions. | Immediate Jeopardy |
| Medication errors exceeding 5% error rate, including failure to administer medications as ordered. | Immediate Jeopardy |
| Failure to provide adequate quality of care, including wound care, bowel management, and pain management. | Immediate Jeopardy |
| Infection prevention and control program deficiencies, including failure to maintain sanitary environment and proper use of PPE. | Immediate Jeopardy |
| Life safety code violations related to sprinkler system maintenance, fire drills, emergency preparedness, and oxygen storage. | Immediate Jeopardy |
Report Facts
Capacity: 71
Census: 48
Deficiencies cited: 7
Medication error rate: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 21, 2023
Visit Reason
An off-site desk audit was conducted on August 21, 2022 for all previous deficiencies cited on July 14, 2022 to verify correction of cited deficiencies.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 8
Jul 14, 2023
Visit Reason
A Recertification Survey and a complaint investigation were conducted to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to Resident Rights, Services Provided Meeting Professional Standards, Comprehensive Care Plans, Quality of Care, Free of Accident Hazards, Residents Free of Significant Medication Errors, Labeling and Storage of Drugs and Biologicals, Infection Prevention and Control, and Life Safety Code compliance. The facility failed to meet several regulatory requirements as evidenced by observations, record reviews, and staff interviews.
Complaint Details
The complaint investigation was substantiated as the facility failed to treat residents with dignity and respect, failed to follow physician orders, failed to maintain a safe environment, and failed to prevent medication errors and infection control issues.
Severity Breakdown
SS=D: 6
SS=E: 1
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of quality of life, specifically related to assistance with eating during meals for Resident ID #34. | SS=D |
| Facility failed to ensure services met professional standards of quality related to following a physician's order for a fluid restriction for Resident ID #213. | SS=D |
| Facility failed to ensure residents receive treatment and care in accordance with professional standards of practice related to administration of blood pressure medication for Resident ID #20. | SS=D |
| Facility failed to ensure the resident environment remains free of accident hazards for Resident ID #34. | SS=D |
| Facility failed to ensure residents are free of significant medication errors for Resident ID #20. | SS=E |
| Facility failed to label and store drugs and biologicals in accordance with accepted professional principles. | SS=F |
| 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 for Resident ID #47. | SS=D |
| Life Safety Code deficiencies related to means of egress; mattresses stored in basement level of exit access hallway. | SS=D |
Report Facts
Reference Numbers: 4
Deficiency Severity Counts: 6
Deficiency Severity Counts: 1
Deficiency Severity Counts: 1
Dates of fluid intake records: 7
Blood pressure readings: 20
Medication administration dates: 4
Audit frequency: 5
Audit frequency: 4
Audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Vaccaro | LNHA | Signed the plan of correction document |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 28, 2022
Visit Reason
An off-site desk audit was conducted on July 28, 2022, to review all previous deficiencies cited on June 15, 2022.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 2
Jun 13, 2022
Visit Reason
A Recertification Survey and a complaint investigation survey were conducted from 06/13/2022 through 06/15/2022 at Crystal Lake Rehabilitation & Care Center to determine compliance with 42 CFR Part 483-Requirements for Long-Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to nutrition/hydration status maintenance and respiratory/tracheostomy care. The plan of correction addresses refusal of weights documentation, identification of other potentially affected residents, staff education, and monitoring effectiveness of corrective actions.
Deficiencies (2)
| Description |
|---|
| Failure to ensure residents maintain acceptable parameters of nutritional status, including sufficient fluid intake and therapeutic diet when needed. |
| Failure to provide respiratory care consistent with professional standards for residents receiving oxygen therapy, including lack of physician orders for oxygen. |
Report Facts
Resident weight loss: 14
Resident count reviewed for nutrition: 4
Residents reviewed for oxygen therapy: 6
Dates of survey: Survey conducted from 06/13/2022 through 06/15/2022
Inspection Report
Annual Inspection
Deficiencies: 12
Mar 31, 2021
Visit Reason
The annual Federal Life Safety Code survey and a Recertification Survey and Complaint Investigation were conducted to determine compliance with federal and state regulations for long term care facilities, including emergency preparedness and resident rights.
Findings
Life Safety Code deficiencies were identified related to the maintenance and documentation of the Emergency Power Supply System. The facility was found not in compliance with resident rights, visitation policies, Medicaid/Medicare coverage notices, quality of care, accident prevention, sufficient nursing staff, resident allergies and preferences, infection control, and medication administration. Plans of correction were submitted for all deficiencies.
Deficiencies (12)
| Description |
|---|
| Facility lacked proper documentation that the generator was being maintained in accordance with NFPA 110. |
| Facility failed to ensure resident had the right to make choices about aspects of his or her life in the facility related to smoking. |
| Facility failed to provide residents the right to receive visitors according to visitation guidelines. |
| Facility failed to provide Medicaid/Medicare coverage notices to residents as required. |
| Facility failed to provide treatment and care in accordance with professional standards related to dental services for residents. |
| Facility failed to provide activities based on resident preferences for a resident in quarantine for COVID-19. |
| Facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident. |
| Facility failed to provide sufficient nursing staff to maintain resident safety and care. |
| Facility failed to provide visitation in accordance with guidelines due to insufficient staff. |
| Facility failed to accommodate resident food preferences for multiple residents. |
| Facility failed to maintain infection prevention and control program to prevent spread of infections including COVID-19. |
| Facility failed to perform hand hygiene and infection control practices during medication administration. |
Report Facts
Deficiencies cited: 12
Resident sample size: 3
Resident sample size: 4
Resident sample size: 1
Resident sample size: 1
Resident sample size: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Vaccaro | LNHA | Signed as Laboratory Director or Provider/Supplier Representative on multiple pages. |
| Director of Nursing Services | Named as responsible party for multiple plans of correction and involved in interviews. | |
| Administrator | Named as responsible party for monitoring corrective actions and involved in interviews. | |
| Activities Director | Named as responsible party for corrective actions related to activities deficiency. | |
| Rehab Director | Named as responsible party for corrective actions related to accident prevention deficiency. | |
| Director of Nursing | Named as responsible party for monitoring infection control corrective actions. |
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