Crystal Lake Rehabilitation and Care Center
999 South Main Street, Pascoag, RI 02859 · Providence County · 71 certified beds · avg 45 residents/day · certified since Sep 1, 1991
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jun 13, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jun 27, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · May 8, 2024 · F-0805
The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Why it matters: Food served in the wrong texture can cause choking or lead residents to stop eating and lose weight.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 29, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Apr 4, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 19, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Dec 7, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 6, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Dec 7, 2023 · F-0740 · triggered by a complaint
The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Why it matters: A resident's untreated mental health needs can worsen and take a toll on their physical health too.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 6, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Sep 25, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 7, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · May 8, 2024 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: May 29, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 27, 2024 · F-0558 · triggered by a complaint
The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Why it matters: Ignoring individual needs — like leaving a call button out of reach — can leave residents helpless, frustrated, or in danger.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 19, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (60)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 17, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 17, 2025 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Apr 17, 2025 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 17, 2025 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 17, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 17, 2025 | B · Minimal risk, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Nov 6, 2024 | F · Potential for harm, facility-wide | The facility employed staff who were not licensed, certified, or registered as required by state law. · from a complaint |
| Nov 6, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Nov 6, 2024 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Sep 25, 2024 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jun 13, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 8, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| May 8, 2024 | ▲ H · Actual harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 8, 2024 | F · Potential for harm, facility-wide | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| May 8, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 8, 2024 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| May 8, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 8, 2024 | F · Potential for harm, facility-wide | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| May 8, 2024 | F · Potential for harm, facility-wide | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| May 8, 2024 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 8, 2024 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 8, 2024 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| May 8, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| May 8, 2024 | E · Potential for harm, repeated | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| May 8, 2024 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 8, 2024 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| May 8, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| May 8, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| May 8, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| May 8, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 8, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 8, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| May 8, 2024 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Apr 4, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 4, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Apr 4, 2024 | E · Potential for harm, repeated | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint |
| Mar 28, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 22, 2024 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Feb 29, 2024 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| Feb 29, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Feb 27, 2024 | ▲ G · Actual harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Feb 27, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · from a complaint |
| Feb 27, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 27, 2024 | B · Minimal risk, repeated | The facility did not let a resident or their legal representative see or buy copies of the resident's own records. · from a complaint |
| Jan 10, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to manage their own money and financial affairs. · from a complaint |
| Dec 7, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 7, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint |
| Dec 7, 2023 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint |
| Dec 7, 2023 | E · Potential for harm, repeated | The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. · from a complaint |
| Sep 12, 2023 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 16, 2023 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jul 14, 2023 | F · Potential for harm, facility-wide | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 14, 2023 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Jul 14, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jul 14, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jul 14, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 14, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 14, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (22 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 13 | 2 | J ▲ |
| 2024 | 41 | 6 | K ▲ |
| 2025 | 6 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
15 fines totaling $306,656, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Sep 25, 2024 | Fine | $29,328 |
| Jun 13, 2024 | Fine | $27,213 |
| Feb 27, 2024 | Fine | $9,318 |
| Feb 27, 2024 | Fine | $10,845 |
| Feb 27, 2024 | Fine | $105,651 |
| Feb 27, 2024 | Payment Denial | 2 days from May 27, 2024 |
| Feb 20, 2024 | Fine | $4,938 |
| Feb 12, 2024 | Fine | $4,938 |
| Jan 22, 2024 | Fine | $14,814 |
| Jan 8, 2024 | Fine | $4,938 |
| Jan 2, 2024 | Fine | $4,545 |
| Dec 11, 2023 | Fine | $13,762 |
| Dec 7, 2023 | Fine | $53,430 |
| Dec 7, 2023 | Payment Denial | 8 days from Dec 29, 2023 |
| Nov 20, 2023 | Fine | $4,587 |
| Nov 13, 2023 | Fine | $4,587 |
| Oct 23, 2023 | Fine | $13,762 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Rhode Island avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.51 | 3.88 | 3.95 | bottom 39% in Rhode Island; bottom 37% in the U.S. |
| Registered Nurse hours | 1.02 | 0.80 | 0.69 | top 23% in Rhode Island; top 15% in the U.S. |
| Weekend total nurse staffing | 3.07 | 3.48 | 3.50 | bottom 32% in Rhode Island; bottom 34% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.90 | 0.55 | 0.48 | top 9% in Rhode Island; top 8% in the U.S. |
| Total nursing staff turnover (%) | 57.6 | 40.6 | 45.8 | bottom 9% in Rhode Island; bottom 20% in the U.S. |
| RN turnover (%) | 57.1 | 37.9 | 42.9 | bottom 20% in Rhode Island; bottom 26% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.58, RN 1.04, weekend 3.13. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Fink, Boruch | Individual | 5% or Greater Direct Ownership Interest | 5% | 04/01/2019 |
| Leifer, Joel | Individual | 5% or Greater Direct Ownership Interest | 48% | 04/01/2019 |
| Oberlander, David | Individual | 5% or Greater Direct Ownership Interest | 48% | 04/01/2019 |
| Hermann, Edward | Individual | W-2 Managing Employee | NOT APPLICABLE | 04/01/2019 |
| Stern, Samuel | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you handle residents who need modified food textures, and how do you make those meals appetizing?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What mental health services do you provide on-site, and who delivers them?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Bayberry Commons | 0.1 mi | Pascoag, RI | ★★☆☆☆ | 3/5 | |
| Overlook Nursing and Rehabilitation Center | 1.8 mi | Pascoag, RI | ★★★☆☆ | 3/5 | |
| Greenville Operations Ri LLC DBA Greenville Skille | 6.7 mi | Greenville, RI | ★☆☆☆☆ | 1/5 | SFF |
| Cedar Haven Operations LLC DBA Lake Forrest Health | 6.9 mi | Smithfield, RI | ★☆☆☆☆ | 1/5 | abuse |
| Stillwater Assisted Living and Skilled Nursing Com | 7.7 mi | Greenville, RI | ★★★★☆ | 4/5 | |
| St Antoine Residence | 8.7 mi | North Smithfield, RI | ★★★★☆ | 3/5 | |
| The Friendly Home | 9.0 mi | Woonsocket, RI | ★☆☆☆☆ | 1/5 | |
| Matulaitis Rehabilitation & Skilled Care | 9.0 mi | Putnam, CT | ★★★★★ | 5/5 | |
| Lydia Taft House | 9.2 mi | Uxbridge, MA | ★★★★★ | 5/5 | |
| Cedar Haven Operations Holding LLC Valley View Hea | 9.9 mi | Woonsocket, RI | ★☆☆☆☆ | 1/5 | abuseSFF |
| Holiday Operator, LLC DBA Holiday Rehabilitation a | 10.4 mi | Manville, RI | ★★☆☆☆ | 2/5 | |
| Westview Health Care Center | 10.6 mi | Dayville, CT | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 415099.