Crystal Lake Rehabilitation and Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF805May 8, 2024

  Based 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. Findings are as follows: 1a. […]

• Immediate jeopardy, isolatedF689Jun 13, 2024

  Based 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. Findings are as follows: Record review of a facility policy titled Elopement states in part, .Elopement is defined as the ability of a resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harm's way .Procedure .The Licensed Nurse will conduct an Elopement Risk Screen on admission, quarterly, and upon change of condition .A care plan will be developed and implemented .The Licensed Nurse will have visual contact with each resident .and/or… […]

• Immediate jeopardy, isolatedF689Apr 4, 2024

  Based 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. Findings are as follows: Record review of a facility reported incident submitted to the Rhode Island Department of Health on 3/29/2024 indicated that Resident ID #1 was found outside of the facility on 3/29/2024. Record review revealed that the resident was originally admitted to the facility in November of 2023 and was transferred to the hospital on 12/31/2023 for a change in mental status. […]

• Immediate jeopardy, isolatedF600Dec 7, 2023

  Based 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. Findings are as follows: On [DATE] the Rhode Island Department of Health (RIDOH) received a facility reported incident that indicates that Nursing Assistant, Staff A, was unable to locate Resident ID #2 during rounds. Staff A continued her search and found Resident ID #2 in his/her roommates bed, Resident ID #1. Resident ID #2 had his/her pants down, his/her sexual organ was semi erect, thrusting Resident ID #1 from behind. Resident ID #1 had his/her arm over Resident ID #2 and was observed kissing Resident ID #1. […]

• Immediate jeopardy, isolatedF740Dec 7, 2023

  Based 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. Findings are as follows: On [DATE] the Rhode Island Department of Health (RIDOH) received a facility reported incident that indicates that Nursing Assistant, Staff A, was unable to locate Resident ID #2 during rounds. Staff A continued her search and found Resident ID #2 in his/her roommates bed, Resident ID #1. […]