Crystal Lake Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Crystal Lake Healthcare and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600Dec 30, 2024

  Complaint #: NJ181767, NJ181768, NJ181846 Based on observations, interviews, medical record review, and review of other pertinent facility documents on 12/23/2024 and 12/30/2024, it was determined that the facility failed to a.) prevent physical and verbal abuse towards a resident (Resident #1) from a staff member and b.) staff members that witnessed the abuse failed to intervene and report the incident. The facility also failed to follow its policy titled Abuse Policy and Procedure. During an interview on 12/23/2024 at 3:08 P.M., the Licensed Practical Nurse (LPN #1) stated she recorded a video on her cellphone of the Director of Nursing (DON) hitting Resident #1 with a broom. LPN #1 sent the video to a friend, and it was posted to a social media website. […]

• Immediate jeopardy, widespreadF610Dec 30, 2024

  Complaint #: NJ181767, NJ181768, NJ181846 Based on observations, interviews, medical record review, and review of other pertinent facility documents on 12/23/2024, it was determined that the facility failed to conduct a timely and thorough investigation for an allegation of witnessed staff to resident physical abuse toward a resident (Resident #1). During an interview on 12/23/2024 at 3:08 P.M., the Licensed Practical Nurse (LPN #1) stated she recorded a video on her cellphone of the Director of Nursing (DON) hitting Resident #1 with a broom. LPN #1 sent the video to a friend, and it was posted to a social media website. The Surveyors and the Assistant Director of Nursing (ADON) reviewed a video on 12/23/2024 at 10:41 A.M. […]

• Immediate jeopardy, widespreadF880Jan 29, 2021

  Based on observation, interview, medical record review, and review of other facility documentation, it was determined that the facility failed to a.) identify all residents exposed to COVID-19 as persons under investigation (PUI), b.) implement mitigation strategies to prevent the transmission of COVID-19 and c.) appropriately implement their Pandemic Influenza/COVID-19 Preparedness & Readiness Plan (Outbreak Response Plan). This deficient practice was identified for 88 of 154 residents, (Residents #1 to #44 who resided on the 6th floor and Residents #45 to #88 who resided on the 7th floor) reviewed for a known exposure to COVID-19 on 2 of 5 nursing units during a focused infection control COVID-19 survey conducted on 1/14/21 and 1/15/21. […]

• Immediate jeopardy, isolatedF689Jan 27, 2026

  Complaint #: 2716119 Based on observations, interviews, review of the medical record, and other pertinent facility documentation, it was determined that the facility failed to protect a resident from self-harm and provide adequate supervision for a resident (Resident #100) with a history of suicidal ideations with plans to cut their wrist prior to admission to the facility, who cut their wrist while residing in the facility. This deficient practice was identified for 1 of 6 residents reviewed for accidents (Resident #100). According to the progress notes, on 1/11/2026 at 10:30 PM, the resident was noted by facility staff with a two-inch laceration to their right wrist that was bleeding profusely. The resident stated, I thought that I was going home, but they said I was not. […]

• Immediate jeopardy, isolatedF600Apr 29, 2025

  Complaint #: NJ185153 Based on interviews, medical record review, and review of other pertinent facility documentation on 4/10/25, it was determined that the facility failed to ensure: a) a staff member immediately reported an observed sexual encounter between a resident (Resident #1) who had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive impairment) from a resident (Resident #2) who had a BIMS score of 8 (moderate cognitive impairment) and b) both residents were immediately separated, safe, and no other residents were placed in immediate danger. The facility also failed to follow its policy titled Resident Abuse/Neglect Policy. On 4/3/25 at approximately 12:00 P.M., the Housekeeper (HK) stated she went to Resident #1 and Resident #2's room and knocked on the door. […]