Health inspection·April 29, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pressure wounds and we have to notify the Wound Care Nurse (WCN). The WCN will complete a detailed assessment. The floor nurse should provide measurements, location of the wound, and a basic description of the wound and any drainage. (The surveyor directed V7 to review R1's admission Assessment and asked what R1's wound looked like.) There is no way to know what it looked like because it just says pressure. (The surveyor asked V7 if she saw any detailed Wound Assessment for R1's sacral pressure wound.) I don't see anything here. V7 said proper documentation of the wound assessment is an important for tracking the wounds progress and ensuring continuity of care for the R1. V7 said she is unsure who initiates the baseline care plan for residents. V7 stated, I think MDS (Minimum Data Set) does that? I really can't speak on it. I don't remember every doing that. On 4/25/25 at 2:00 PM, V4 (WCN) said she started with the facility around the third week of February 2025. V4 said she was not working at the facility when R1 was there. V4 said all new admissions should have an initial skin assessment. V4 said if it is during them week, the nurse will notify her if there is a wound and she usually does a thorough wound assessment within 24 hours. V4 said the floor nurse can provide a basic description, including the location, size, appearance of the wound and if there is any drainage. V4 said the initial wound assessment is important to track the wounds progress, determine if the treatments regimen needed to be altered, and to prevent the risk of infection. The surveyor showed V4, R1's admission assessment dated [DATE] that showed, pressure, to the sacrum and R1's Skin Assessment Weekly dated 10/28/24 that showed R1 had an open area to her sacrum. The surveyor asked V4 if R1's documentation provided the proper assessment details of a pressure wound. V4 replied, Absolutely not. The baseline assessment is very important, so everyone knows the starting point. V4 said a proper wound assessments includes: measurements; location; description of the wound bed and wound edges; staging for pressure ulcers; and a description of drainage. V4 said if R1 had a pressure wound on admission, then R1 should have had a baseline care plan initiated within 24 hours to address R1's individualized care needs. V4 said the Care plan is a tool to communicate the R1's care needs to the care team. On 4/25/25 at 2:21 PM, V2 (Director of Nursing - DON) said she did not recall R1, but she was looking through R1's record for Skin Assessments. R1 provided the Skin Assessment Weekly dated 10/28/24 (showing an open wound to R1's sacrum, but no further description of the wound). V2 said there should be a detailed initial pressure ulcer assessment and weekly pressure ulcer assessment. V2 said based the information documented, there was no way to know what R1's sacral pressure ulcer looked like. V2 said the facility does not use shower sheets and she had reviewed all the possible places the nurse should have documented a thorough wound assessment. V2 said she could not locate one. V2 said a baseline care plan should be initiated within 24-48 hours of admission. V2 said R1's admission Assessment showed she had pressure to her sacrum, so R1's care plan should have reflected there was a skin integrity concern. V2 stated, I do see a wound care consult ordered. There isn't usually a Wound Care consult unless the resident had a wound. The whole thing is very confusing. The facility's Pressure Injury Assessment and Treatment Policy dated 1/2025 showed, The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified alterations in skin integrity, pressure injuries, and the prevention of acquiring additional alterations in resident skin integrity . General Guidelines: A. The pressure injury treatment program should focus on the following strategies: a. Evaluating the resident, understanding current risk level, and/or the status of existing skin alteration and/or pressure injuries .Documentation: The following information should be recorded in the resident's electronic medical record. A. Document type of wound and location: a. Stage of the wound in pressure. b. Use anatomical location in description. B. Partial thickness or Full thickness. C. Wound measurements: a. Head to toe (Length). (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 04/29/2025 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 0686 b. Left to right (Width). c. Depth. D. Level of Harm - Minimal harm or potential for actual harm Undermining, tunneling, or sinus tract: a. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Clock method (12 o'clock represents residents head, 6 o'clock represents resident's feet. E. Exudate (Drainage): a. Type. b. Color. c. Amount. d. Odor. i. Absence or presence of odor and describe the smell. F. Wound bed: a. Adherence of tissue (slough or eschar). b. Types of tissue visualized in wound bed. c. Amount of visible tissue: i. Describe in percentage amounts tissue types that make up the wound bed. ii. Can you use the clock system to describe location of varying tissue types. d. Debris or foreign bodies. G. Describe wound edges: a. Definition (defined or undefined). b. Attachment. c. Border shape. d. Maceration, epibole, fibrotic, callused etc. H. Describe Peri-Wound (Surrounding tissue). I. Describe any indications of possible infection. J. Pain: a. Causative factors. b. Duration. c. Intensity. d. Intervention for pain relief and effectiveness. K.Document interventions for healing . Event ID: Facility ID: 145257 If continuation sheet Page 3 of 3