Crystal Pines Rehab & Hcc

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's safety during an outdoor activity.

This applies to 1 of 3 residents (R2) reviewed for safety and supervision in the sample of 5.The findings include:R2's electronic face sheet printed on 11/24/25 showed R2 has diagnoses including but not limited to type 2 diabetes, constipation, CHF, vascular dementia without behaviors, repeated falls, and peripheral vascular disease.R2's facility assessment dated [DATE] showed R2 had mild cognitive impairment.The facility's incident report dated 11/15/25 showed, This writer was notified by the weekend staff nursing supervisor that (R2) received a bite from a visiting domesticated horse and received a small laceration to the hand.

The horse was under the supervision of its handler when the incident occurred .R2's progress notes dated 11/15/25 showed, Resident attempted to feed a horse during activities, but was accidently bit on the left 4th digit.

She sustained an abrasion .resident was complaining of mild pain in the area rating the pain a 3/10.Area was cleansed with normal saline; bacitracin was applied with gauze.

Since resident was previously started on oral antibiotics for a urinary tract infection, nurse practitioner stated that resident will be protected from the bite.

She also ordered a TDAP (Tetanus, Diphtheria, and Pertussis vaccine to be given and to monitor resident vitals and report any abnormal vitals .R2's wound assessment dated [DATE] showed, Left fourth digit: wound measures 0.69x0.58x0.2cm with sanguineous (blood) drainage.On 11/21/25 at 11:32AM, V1 (Administrator) stated, We were trying to get the residents outside to do an activity so when (V10-Certified Nursing Assistant) volunteered to bring her horses here we thought it would be a good idea. 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. I think (R2) 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. 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 R2 or something.The facility was unable to provide a policy regarding resident safety during outdoor activities.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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