Inspection·December 21, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide ongoing monitoring of a resident for 1 of 3 residents (R1) reviewed for quality of care in the sample of 5. Residents Affected - Few The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include acute on chronic systolic and diastolic heart failure, cardiomegaly, chronic obstructive pulmonary disease, dependence on supplemental oxygen, hypertensive heart and chronic kidney disease with heart failure and with Stage 5 Chronic Kidney Disease, paroxysmal atrial fibrillation, pressure ulcer of sacral region, pulmonary hypertension, atherosclerosis of coronary artery bypass grafts, chronic respiratory failure with hypoxia, dependence on renal dialysis, dysphagia, occlusion and stenosis of carotid artery, pericardial effusion, peripheral vascular disease, and pressure induced deep tissue damage of left heel. R1's facility assessment dated [DATE] showed she had moderate cognitive impairment and required substantial to maximum assistance with bed mobility, transfers, and toileting. This same assessment showed R1 to be at risk for and to have a pressure injury. R1's care plan initiated [DATE] showed, [R1] has pressure injuries to the left heel and coccyx related to recent hospitalization, impaired mobility . Remind patient to change positions frequently . R1's care plan initiated [DATE] showed, The resident is (high risk) for falls related to deconditioning, gait/balance problems, psychotropic medications, shortness of breath Staff will check residents' location and activity to ensure if resident is properly and safety positioned in bed or chair . R1's care plan initiated [DATE] showed, The resident has had an actual fall with no injury . Staff will assess and anticipate residents personal and ADL (activities of daily living) needs such as toileting, incontinence care, grooming, eating . during rounds. Staff will attend to needs as they are identified . R1's complete medical record was reviewed and showed she was assisted to the toilet at 9:41 PM on [DATE]. R1's record showed she had a Loop Recorder (device that monitors heartbeats) implanted [DATE]. The company who receives the information downloaded from R1's loop recorder provided a document that showed R1 had a cardiac event which led to R1's death on [DATE] at 1:04 AM. R1's [DATE] 6:30 AM nursing note showed, Entered room to give medications, noted unresponsive, no respirations or pulse. Yelled for help and initiated CPR (cardiopulmonary resuscitation) immediately (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: 145612 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 145612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Crystal Lake, The 1000 East Brighton Lane Crystal Lake, IL 60012 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)