Health inspection·December 11, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indwelling urinary catheter from the nursing home; tubing clogged with sediment and stained orange. The catheter tip was corroded in sediment. Indwelling urinary catheter replaced with a new catheter per ER doctor. The ER Physician's Note showed, ED (Emergency Department) Course as of 12/5/24 6:03 AM: 2:52 AM Indwelling catheter tubing appears to have a lot of sediment and no active drainage upon arrival to the emergency room. After removal of the indwelling urinary catheter, patient had a large amount of bloody urine draining spontaneously, followed by several blood clots, new catheter was placed and patient continued to drain another 400 cc of cloudy fluid, followed by milky thick urine. Gross hematuria spontaneously improved. At 3:23 AM - I spoke with the nursing home nurse .who reports she noticed the patient having trouble breathing and gurgling respirations around midnight Unknown when last catheter was changed. On 12/10/24 at 1:00 PM, V2 DON (Director of Nursing) reviewed R1's ER Nurse's Note and stated she was not aware of any problem with R1's catheter. V2 stated if the catheter tubing was leaking or looked old, had built up secretions, or wasn't draining properly the catheter should have been changed. V2 stated staff should be monitoring the catheter and if it looks bad it should be changed. V2 stated it was not typical to not change a catheter in an 8-month time. V2 stated when a catheter is changed it should be documented on the TAR (Treatment Administration Record). On 12/10/24 at 1:46 PM, V7 RN (Registered Nurse) stated she charts by exception. V7 stated when assessing a catheter, she starts distally to see where the drainage bag is placed; it should be off the floor. V7 stated she looks at the out put of urine as well as the color and consistency of the urine. V7 stated she looks at the insertion site to see if there is any drainage or leaking. V7 stated she changes a catheter if she notices the urine is cloudy, if there is any blood present or if the resident has pain. V7 stated she documents any placement of a catheter or catheter change in the progress notes. V7 stated as far as she new a resident should have catheter changes every 4 or 6 weeks or a rationale as to why the catheter should not be changed. V7 stated not changing a catheter for a long period of time would not be best practice. V7 stated the facility has admission orders; at that time the parameters for catheters and when they are changed should be entered. On 12/10/24 at 5:18 PM, V6 RN stated R1 was her patient in the ER. V6 stated R1 had a catheter in place that looked horrible. The tubing was stained orange. V6 stated she had never seen anything like it. V6 stated the catheter was clogged and not draining so they removed the catheter. The catheter tip appeared corroded and there was blood present. V6 stated R1's urine had a foul odor. V6 stated when they placed the new catheter there wasn't any blood in the drainage bag but there was pus, and the urine was cloudy. V6 stated R1 had a urinary tract infection. V6 stated the ER physician called the nursing home, spoke with the nurse and she did not know when the last time R1's catheter had been changed. The facility's Infection Prevention and Control Manual Resident care - Prevention of Catheter-Associated Urinary Tract Infections policy (2019) showed changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. If an obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. 2. The Face Sheet dated 12/10/24 for R3 showed diagnoses including chronic obstructive pulmonary disease, retention of urine, chronic respiratory failure with hypoxia, obstructive and reflux (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145257 If continuation sheet Page 2 of 3 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 145257 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Pines Rehab & Hcc 335 North Illinois Avenue Crystal Lake, IL 60014 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few uropathy, venous insufficiency, congestive heart failure, peripheral vascular disease, type 2 diabetes mellitua, asthma, obstructive sleep apnea, hypertension, hyperlipidemia, neuropathy, edema, and atrial fibrillation. The Care Plan dated 11/29/24 for R3 showed, R3 has a catheter due to obstructive uropathy. R3 will show no signs/symptoms of urinary infection through the next review date. Catheter care every shift and as needed. Position catheter bag and tubing below the level of the bladder and away from the entrance room door. Monitor/report to medical doctor for signs of UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urgency/frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or change in eating patterns. On 12/10/24 at 11:32 AM, V5 CNA (Certified Nursing Assistant) and V4 CNA were at R3's bedside to provide bowel incontinence care and catheter care. V4 and V5 had gowns and gloves on. R3 was laying in bed on her back with her catheter drainage bag in a bag holder on the lower side of the bed. R3's catheter tubing showed cloudy urine with sediment present. V4 used disposable wipes to clean the stool off from R3's groin and vagina. V4 changed her gloves, used a disposable wipe and cleaned the catheter tubing from the urinary meatus and away from the resident. V5 took the drainage bag and handed across the bed, holding it at her chest level and above the resident's bladder when giving the drainage bag to V4. R3 stated, keep the bag down otherwise the urine is going to go back down the tube, and I will get an infection. It also hurts when it (urine) goes backwards. V4 and V5 nodded yes and then stated R3 was a retired nurse. R3 was turned onto her side and V4 cleaned her buttocks with disposable wipes. V4 picked the drainage bag up and sat it on the end of the bed. V5 picked the drainage bag up from the bed and placed it on the lower side of the bed. V5 picked the drainage bag up and emptied 2300 ml of urine from the bag. V4 and V5 stated the drainage bag should not be above the resident's bladder because urine can flow back and cause an infection. V4 and V5 stated the drainage bag should not go on the bed for infection reasons. On 12/10/24 V2 DON (Director of Nursing) stated the drainage bag should always be kept below the level of the bladder. V2 stated the drainage bag should not be on the bed due to infection control. The facility's Infection Prevention and Control Manual Resident care - Prevention of Catheter-Associated Urinary Tract Infections policy (2019) showed, keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145257 If continuation sheet Page 3 of 3