Inspection·April 15, 2025

F 0801 dishes and started to put them away. Level of Harm - Minimal harm or potential for actual harm On 4/15/25 at 9:22 AM, V6 said she started working at the facility on 4/14/25. V5 (Dietary Aide) was training V6 how to clean up the beverage carts after breakfast. V5 instructed V6 to take a clear, two-inch pan full of ice and water, dump the ice and water into a nearby sink, then dip the pan into the third sink (sanitizer sink) of the three-compartment sink. V5 and V6 repeated this process for a total of four pans. None of the pans were left in the sanitizer sink for at least one minute. After the pans, V5 and V6 began emptying coffee pitchers from breakfast. V5 told V6 that the middle sink in the set-up and ready three-compartment sink was known as the dumping sink where employees discard leftover liquids from cups and pitchers before washing them. V5 asked V7 if that was correct and V7 agreed. When V5 asked V4, V4 said that the middle sink was not for dumping discarded liquids into and was for rinsing already washed dishes. Residents Affected - Many On 4/15/25 at 10:50 AM, V4 said staff should wash hands when going from dirty dishes to clean dishes. Facility did not have a policy and procedure related to required dietary staff training. Facility Dish Machine Operation policy (no date) states, The Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food . 7. Follow the procedure for proper preparation and loading of dishes into the dishwashing machine. The standard sequence is as follows: c. Stack dishes in racks using correct procedure for that style rack . f. Use clean, washed hands to pull out clean racks, and allow to air dry before putting dishes away for storage . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145257 If continuation sheet Page 2 of 5 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 04/15/2025 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to ensure correct food service scoops were used to serve mashed potatoes. This has the potential to affect all 73 residents in the facility. Residents Affected - Many Findings include: Facility Data Sheet dated 4/15/25 shows the facility has a total census of 73 residents. On 4/15/25 at 12:10 PM, V1 (Interim Administrator) said the facility does not currently have any residents that receive a tube feeding or have an order of NPO (nothing by mouth). On 4/15/25 at 11:40 AM, V4 (Cook) said the food supplier did not bring the lunch meal on time to serve the country fried steak on Monday. V4 said for lunch on 4/15/25 they will be serving country fried steak with gravy, mashed potatoes, gravy, and a breadstick. V4 said V4 and other cooks usually get the scoops set up and ready for serving and the dietary aides will serve lunch. V4 showed this surveyor where the binder was that listed the portion and scoop sizes to use for each meal and stated that the dietary aides also know where it is and have access to it when needed. On 4/15/25 at 11:25 AM, V4 placed a green handled number 12 scoop (which provides 2 2/3 ounces) into the mashed potatoes. On 4/15/25 at 11:38 AM, V7 (Dietary Aide) started service, providing one scoop of mashed potatoes to every single plate. Facility diet spreadsheet shows the portion size for mashed potatoes is 4 ounces. On 4/15/25 at 11:47 AM, V11 (Regional Director of Operations- Kitchen) said the menus and recipes should be followed, including using the appropriate scoop listed. If the menus are followed as written, the nutritional needs of the residents should be met. Facility Standardized Recipes policy (no date) states, Standardized recipes will be used for all menu items, including pureed and therapeutic diets . 1. Each standardized recipe will include the following: . g. Serving sizes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145257 If continuation sheet Page 3 of 5 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 04/15/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure employees practiced safe food handling practices resulting in risks of cross-contamination. This has the potential to affect all 73 residents in the facility. Findings include: Facility Data Sheet dated 4/15/25 shows the facility has a total census of 73 residents. On 4/15/25 at 12:10 PM, V1 (Interim Administrator) said the facility does not currently have any residents that receive a tube feeding or have an order of NPO (nothing by mouth). 1. On 4/15/25 between 9:15 AM and 9:30 AM, V7 (Dietary Aide) was continually observed doing dishes at the dish machine wearing gloves. V7 started by breaking down breakfast trays, discarding food debris and waste, and placing all trays, plate tops, cups, and utensils into dish racks. When the dish rack was full, V7 would place the dish rack into the dish machine and pull down the handle to run the automatic run cycle. When the cycle finished, V7 would pull the dish rack out of the dish machine and place the rack on the out-feed table to dry. V7 continued this process until the out-feed table became full with clean and sanitized dish racks. After handling the dirty dishes and without changing gloves or washing hands, V7 proceeded to remove the clean and sanitized dishes from the dish racks and put the clean and sanitized dishes away. On 4/15/25 at 10:50 AM, V4 (Cook) said all employees should wash hands after handling dirty dishes before touching clean and sanitized dishes. Facility Dish Machine Operation policy (no date) states, The Dining Services staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in this guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food . 7. Follow the procedure for proper preparation and loading of dishes into the dishwashing machine. The standard sequence is as follows: c. Stack dishes in racks using correct procedure for that style rack . f. Use clean, washed hands to pull out clean racks, and allow to air dry before putting dishes away for storage . 2. On 4/15/25 at 9:03 AM, V4 started washing pots and pans in the three-compartment sink. V4 would use the first sink to wash all items with soap and water, the second sink to rinse with plain water, and the third sink to sanitize with a pre-diluted mixture of water and sanitizer. V4 washed a total of 7 pans, placed them in the middle sink to rinse, and dipped the pans into the third sanitizing sink for less than ten seconds each before placing them to the side to air dry. On 4/15/25 at 9:22 AM, V5 (Dietary Aide) and V6 (Dietary Aide) were cleaning up the beverage carts that were sent to the units for breakfast. V5 grabbed a clear two inch pan filled with ice and water and brought it to the dish machine area to show V6 how to clean the pans. V5 dumped the ice and water into a nearby sink, then proceeded to dip the clear pans into the third, sanitizer sink and immediately pulled them out and placed them to air dry. V5 and V6 continued this process with four clear pans and some coffee pitchers. On 4/15/25 at 10:50 AM, V4 said all items placed in the sanitizer sink should remain submerged for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145257 If continuation sheet Page 4 of 5 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 04/15/2025 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 0812 at least one minute for them to be fully sanitized. Level of Harm - Minimal harm or potential for actual harm 3. On 4/15/25 at 10:12 AM, a visibly soiled food service scoop was stored inside the bulk flour storage bin, resting inside of the flour. Residents Affected - Many On 4/15/25 at 10:50 AM, V4 said scoops should not be stored inside of bins. Facility provided Utensil Storage policy (no date) states, Employees will store utensils, tableware, and equipment according to the following guidelines . 5. Cleaned and sanitized equipment and utensils should be handled in a way that protects them from contamination . 4. On 4/15/25 at 8:54 AM, there were eight serving pitchers in the reach in cooler that contained a variety of juices and lemonade that were not labeled or dated. On 4/15/25 at 9:26 AM, V5 and V6 were cleaning up the beverage carts that were sent to the units for breakfast. V5 told V6, We are supposed to label these (juice and milk pitchers). I don't know why they are not labeled. On 4/15/25 at 10:50 AM, V4 said all items in the fridge should be labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145257 If continuation sheet Page 5 of 5