The November 15 incident at Crystal Pines Rehab & HCC involved a resident with type 2 diabetes, congestive heart failure, vascular dementia, and a history of repeated falls. The resident, identified in records as having mild cognitive impairment, was participating in a horse feeding activity when the animal bit her left fourth finger.
"Resident attempted to feed a horse during activities, but was accidently bit on the left 4th digit," nursing notes from the day stated. The resident complained of mild pain, rating it a 3 out of 10. Staff cleaned the wound with saline solution and applied antibiotic ointment with gauze.
The facility's incident report described the injury as occurring while "the horse was under the supervision of its handler." A subsequent wound assessment measured the laceration at 0.69 by 0.58 by 0.2 centimeters with blood drainage.
Administrator V1 explained the circumstances during an interview with state inspectors on November 21. "We were trying to get the residents outside to do an activity so when [the certified nursing assistant] volunteered to bring her horses here we thought it would be a good idea," the administrator said.
The administrator acknowledged the activity's risks in hindsight. "In hindsight I guess we could have just had her ride the horse and show it and maybe have the residents pet the horse and not feed it."
She described the resident's engagement during the incident. "I think [the resident] was just happy to be doing the activity and wasn't paying attention and the horse was eating out of her hand and then it bit her finger."
The administrator speculated about preventing similar incidents. "I'm not sure how we really could have prevented it except for not having the residents hold the food in their hand. I don't think the horse has ever bit anyone before but maybe it just got nervous because it didn't know [the resident] or something."
Because the resident was already receiving oral antibiotics for a urinary tract infection, the nurse practitioner determined she would be protected from potential infection from the bite. However, staff still administered a TDAP vaccine covering tetanus, diphtheria, and pertussis as a precaution.
The nursing staff was instructed to monitor the resident's vital signs and report any abnormal readings following the incident.
When inspectors requested the facility's policy regarding resident safety during outdoor activities, administrators could not provide one. This absence of written safety protocols for outdoor programming contributed to the state's finding that Crystal Pines failed to ensure adequate supervision to prevent accidents.
The incident occurred during a weekend, with the weekend nursing supervisor notifying administrators about the horse bite and resulting laceration. A certified nursing assistant had volunteered to bring her personal horses to the facility for the resident activity.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The finding applied to one of three residents reviewed for safety and supervision in a sample of five residents examined during the complaint investigation.
The resident's medical history complicated the incident's aftermath. Beyond her dementia and diabetes, she also suffered from constipation and peripheral vascular disease, conditions that can affect wound healing and infection risk in elderly patients.
Staff documentation showed the horse bite created an abrasion on the resident's finger, requiring ongoing wound care and monitoring. The facility treated the injury as they would any laceration, with cleaning, antibiotic ointment, and protective dressing.
The administrator's reflection on the incident revealed the challenge of balancing engaging activities with resident safety. While the horse visit was intended to provide outdoor stimulation for residents, the feeding component introduced risks that administrators hadn't fully considered beforehand.
The absence of written safety protocols for outdoor activities left staff without clear guidelines for supervising residents during animal interactions. The facility's inability to produce such policies during the inspection highlighted a gap in their safety planning for non-routine activities.
The resident's cognitive impairment, documented as mild but occurring alongside vascular dementia, may have affected her ability to safely interact with the animal. Her history of repeated falls already marked her as requiring careful supervision during activities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crystal Pines Rehab & Hcc from 2025-11-21 including all violations, facility responses, and corrective action plans.