Crystal Pines Rehab & Hcc
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
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 (Resident R2) reviewed for safety and supervision in the sample of 5.The findings include:Resident R2's electronic face sheet printed on 11/24/25 showed Resident R2 has diagnoses including but not limited to type 2 diabetes, constipation, CHF, vascular dementia without behaviors, repeated falls, and peripheral vascular disease.Resident R2's facility assessment dated [DATE REDACTED] showed Resident 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 (Resident 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 .Resident 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 .Resident R2's wound assessment dated [DATE REDACTED] 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 (Resident 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 Resident 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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
CRYSTAL PINES REHAB & HCC in CRYSTAL LAKE, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CRYSTAL LAKE, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CRYSTAL PINES REHAB & HCC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.