Inspection·February 3, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy for weighing residents and failed to follow physician orders to weigh resident weekly, which resulted in a 6% unplanned weight loss. This failure applied to one of one (R1) residents reviewed for weight loss. Residents Affected - Few Findings include: R1 an [AGE] year-old male admitted to the facility on [DATE] with the medical diagnosis including but not limited to chronic obstructive pulmonary disease, dementia, hypertension, gait disturbances, and vasovagal syncope. According to R1's weight log found in the electronic medical record, only weights documented were for 1/04/2025, 1/10/2025 and 1/17/2025. Physician orders dated 01/09/2025 include: weekly weights for 4 weeks. R1 had no weights documented from 1/18/2025 to 2/1/2025. 02/2/2025 at 11:49AM R1's family member said, I was not notified of R1's weight loss. 02/01/2025 at 3:52PM V7 (Licensed Practical Nurse) said, I do not see weights charted after 1/17/2025 and the order says it should be done weekly. 2/01/2025 3:55PM V6 (Wound Nurse) was sitting by the nursing station and said, I am a supervisor and I can have someone get the weight for you. 02/02/2025 at 11:55AM V2 (Assistant Administrator) provided weight records that showed 1/04/2025 admitting weight was 180 pounds and on 2/2/2025 weight was 169 pounds. R1 had a total of 11 pounds weight loss from 01/04/25 to 2/2/25, this was a 6% weight loss in a one month period. 2/03/2025 at 11:29AM V17 (Nurse Practitioner) said, I saw R1 last 1/22/2025 after a fall and possible discharge home. I was not aware of any weight loss until yesterday when the facility called me. Weight loss can be attributed to many factors such as illness, poor appetite, not liking the food, and diuretics. Some of intervention to monitor weight loss that I would orders are blood work, check weights weekly, and consult a dietitian. I am available in the building Monday to Friday and nursing staff can call as needed. 02/03/2025 at 11:50 AM V18 (Consultant Dietitian) said, I was only informed of R1's weight loss (continued on next page) 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 Page 1 of 2 Event ID: 145220 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145220 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pine Crest Health Care 3300 West 175th Street Hazel Crest, IL 60429 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)