Crystal Pines Rehab & HCC
Crystal Lake, Illinois · CCN 145257
49 surveys since 2011, 16 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 146
- Surveys
- 49
- Harm or worse
- 16
- Immediate jeopardyall corrected before survey
- 2
Findings at the most serious level CMS records. All were recorded as past non-compliance — corrected before the survey.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 110
- Ownership
- For profit - Corporation
- Chain
- TUTERA SENIOR LIVING & HEALTH CARE
- County
- Mc Henry
- Medicare-certified since
- 1973
CMS ratings
- Overall
- 1
- Health inspection
- 2
- Staffing
- 1
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat more weighted findings than its peer group.
Weighted by harm level, against 110 for-profit facilities of 100–127 beds in Illinois.
Last survey on record
Jun 11, 2026
151 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.15 | 3.16 |
| Registered-nurse hours per resident day | 0.83 | — |
| Annual nurse turnover | 55.7% | 48.7% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $130,776 across 4 penalties
- Payment denials
- 1
- Abuse icon
- Flagged by CMS on Care Compare
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J12.1% | K— | L— |
| Actual harm | G612.5% | H— | I— |
| No harm, potential for more than minimal | D2756.3% | E510.4% | F918.8% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6896×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F6023×
Protect each resident from the wrongful use of the resident's belongings or money.
- F6903×
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- F8123×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F5502×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
In the surveyor’s words
From the most serious findings on record at Crystal Pines Rehab & HCC, in the surveyor’s own words.
- Immediate jeopardy, isolatedF600Nov 14, 2024
Based 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. […]
- Immediate jeopardy, isolatedF689Nov 29, 2022
Based on observation, interview, and record review, the facility failed to accurately assess a resident at risk for elopement and failed to implement interventions to prevent a resident from eloping. These failures resulted in R1 eloping from the facility and being found two blocks away in 34-degree Fahrenheit (F) weather while crawling across a heavily traveled highway. This applied to one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/20/22 when staff were unable to locate R1 inside the facility. V1 (Administrator) was notified of the Immediate Jeopardy on 11/23/22 at 9:09 AM. […]
- Actual harm, isolatedF693May 6, 2026
Based 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.The findings include:R1's face sheet showed she was admitted to the facility 9/24/2020 with diagnoses to include hypokalemia, dysphagia, gastrostomy status, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, major depressive disorder, and anxiety disorder. […]
- Actual harm, isolatedF689Apr 20, 2026
Based 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. Findings include: R1's face sheet shows R1's diagnoses including Alzheimer's Disease, muscle weakness, and a non-displaced type 2 dens fracture.R1's current care plan shows R1 is at risk of falls and requires staff assistance with toileting and transfers. […]
- Actual harm, isolatedF689Oct 14, 2025
Based 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.Findings include:R1's Face Sheet dated October 14, 2025, shows R1 was admitted to the facility on [DATE], with a diagnosis of senile degeneration of the brain. R1's Care Plan initiated September 1, 2025, shows R1 has an activity of daily living self-care performance deficit related to dementia and anxiety disorder. […]
Read 31 findings in full →The most serious and the most recent: 31 of 146 on record.
Every survey on record
FindingsAt actual harm or above
- Jun 11, 2026Complaint1 finding
- May 6, 2026Complaint1 finding · 1 harm
- Apr 20, 2026Complaint1 finding · 1 harm
- Dec 3, 2025Complaint1 finding
- Nov 21, 2025Complaint1 finding
- Oct 14, 2025Complaint1 finding · 1 harm
- Aug 20, 2025Complaint1 finding
- Apr 29, 2025Complaint1 finding
Show the 41 earlier surveys
- Apr 15, 2025Complaint3 findings
- Feb 24, 2025Complaint1 finding
- Jan 8, 2025Complaint2 findings
- Dec 11, 2024Complaint1 finding
- Nov 27, 2024Complaint1 finding
- Nov 14, 2024Complaint2 findings · 1 harm
- Jul 18, 2024Complaint1 finding
- Jun 5, 2024Standard11 findings · 1 harm
- Mar 26, 2024Complaint1 finding
- Jul 19, 2023Standard9 findings · 2 harm
- Mar 30, 2023Complaint2 findings
- Feb 15, 2023Complaint1 finding
- Jan 17, 2023Complaint2 findings · 2 harm
- Dec 8, 2022Complaint1 finding · 1 harm
- Nov 29, 2022Complaint1 finding · 1 harm
- Aug 24, 2022Standard and complaint9 findings
- Jul 6, 2022Complaint1 finding · 1 harm
- Apr 15, 2022Complaint2 findings
- Nov 18, 2021Standard7 findings · 1 harm
- Oct 21, 2021Complaint1 finding
- Oct 4, 2021Infection control1 finding
- Aug 30, 2021Complaint2 findings
- Jun 10, 2021Complaint1 finding
- Jan 21, 2021Standard4 findings
- May 9, 2019Standard8 findings
- Apr 10, 2019Complaint1 finding
- Jun 20, 2018Standard6 findings
- Jul 12, 2017Standard4 findings
- Aug 10, 2016Complaint1 finding
- May 31, 2016Complaint1 finding
- May 19, 2016Standard8 findings
- May 3, 2016Complaint1 finding · 1 harm
- Dec 22, 2015Complaint1 finding
- Jun 11, 2015Standard12 findings
- Jan 27, 2015Complaint1 finding
- Jul 9, 2014Standard5 findings
- Mar 13, 2014Complaint2 findings
- Aug 26, 2013—10 findings
- Jun 28, 2012—1 finding
- Nov 28, 2011—1 finding
- Aug 23, 2011—8 findings · 2 harm
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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