Inspection·February 22, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm including bed mobility, transfers, dressing, eating, and toileting. R2 has bowel incontinence related to decreased mobility; provide bedpan and provide pericare after each incontinence episode. The MDS (Minimum Data Set) dated 11/23/23 for R2 showed no cognitive impairment; dependent on staff for eating, hygiene, dressing, bed mobility, and transfers. Residents Affected - Some 2. On 2/20/24 at 11:01 AM, R4 stated she came to the facility on 1/23/24 for therapy and would be leaving on 2/23/24. R4 stated she had a concern with her call light. R4 stated at night it can take up to two hours to get any help once she has turned on her call light. R4 stated it upset her and she shed a few tears over it. R4 stated a few weeks ago on a Saturday night she put her call light on because she needed pain medication for her arthritis, and it took her 2 hours to get the medication because of her call light not being answered in a timely. R4 stated once the nurse knew she needed medication it was brought to her. R4 stated she never calls for anything unless it is important. The Face Sheet dated 2/21/24 for R4 showed medical diagnoses including respiratory syncytial virus, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity, psoriatic arthritis, iron deficiency anemia, hypomagnesemia, depression, anxiety, hypertension, atherosclerotic heart disease, and deep venous thrombosis. The Care Plan dated 2/7/24 for R4 showed she is at risk for falls related to weakness, deconditioning and unsteadiness. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. The MDS dated [DATE] for R4 showed no cognitive impairment; partial/moderate assistance needed for toileting hygiene, personal hygiene, lower body dressing, and bed mobility. 3. On 2/21/24 at 9:19 AM, R50 was sitting up in bed on an air mattress and had a wound vacuum in place for a wound to her sacrum. R50 stated at nighttime she has had to wait an hour for someone to answer her call light. R50 stated she gets aggravated at the call light not being answered for an hour because she has pain due to the wound on her butt. R50 stated she puts her call light on because she needs pain medication and once it is answered the nurse brings the medication right away. The Face Sheet dated 2/21/24 for R50 showed medical diagnoses including encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg above knee, chest pain, atherosclerotic heart disease, pneumonia, chronic obstructive pulmonary disease, myelodysplastic syndrome, type 2 diabetes mellitus, secondary malignant neoplasm of breast, congestive heart failure, stage 4 pressure ulcer of the sacral region, non-pressure chronic ulcer of the right lower leg, neuromuscular dysfunction of the bladder, hypothyroidism, thrombocytopenia, hyperlipidemia, and anxiety disorder. The Care Plan printed 2/21/24 for R50 showed she has an ADL (activity of daily living) performance deficit related to weakness and deconditioning following left above knee amputation. Encourage resident to use call light for assistance. The resident is at high risk for falls related to a history of a fall. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. The MDS dated [DATE] for R50 showed no cognitive impairment. 4. On 2/20/24 at 10:03 AM, R40 was sitting up in bed with the head of his bed elevated and wearing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 2 of 16 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 02/22/2024 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)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a hospital type gown. R40 had an air mattress in place. R40 stated he has waited as long as two hours for someone to answer his call light. R40 stated, I have had to text my wife and then she calls them and then they come and check on me. The way I look at it is if you turn the light on you do it for a reason. I was at another place and turned my call light on because I was having problems speaking. They came in shut the light off and didn't help me. They came back later and sent me out because I had a stroke. R40 stated he was worried that this could happen again when staff don't respond to call lights like they should. On 2/21/24 at 2:27 PM, V3 went to R40's room and he was laying on his back in bed with the head of the bed elevated. V12 (R40's wife) was at his bedside. R40 stated he did get his catheter changed this morning at 5:00 AM. R40 stated he waited 1 hour for anyone to answer his call light and he texted his wife. V12 stated R40 texted her at 4:45 AM stating he had been waiting an hour for his call light to be answered so she contacted the nurse at the facility. R40 was having abdominal pain and back pain; felt awful and could not urinate. V12 and R40 stated they couldn't get his catheter irrigated so the night nurse replaced it. V12 stated on Saturday night this happened too, R40 was waiting a long time for someone to answer the call light. The Face Sheet dated 2/21/24 for R40 showed medical diagnoses including multisystem degeneration of the autonomic nervous system, left side hemiparesis and hemiplegia following cerebral infarction, dysphagia, dysarthria, benign prostatic hyperplasia, neuromuscular dysfunction of the bladder, hypertension, and hyperlipidemia. The Care Plan printed on 2/21/24 for R40 showed he has an ADL self-care performance deficit and impaired mobility related to weakness, deconditioning, and hemiplegia post cerebral vascular accident. Encourage the resident to use bell to call for assistance. R40 is at risk for falls related to multiple syncope, orthostatic hypotension, recent cerebral vascular accident with left sided hemiplegia/ataxia, and weakness/deconditioning. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. The Minimum Data Set, dated [DATE] for R40 showed no cognitive impairment. The facility's Resident Right - Exercise of Rights policy (6/9/22) showed the facility will treat each resident with respect and dignity and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Each resident will be treated with dignity and respect. The facility's Call Light Use policy (7/6/23) showed the facility aims to meet resident's needs as timely as possible. Call light system is utilized to alert staff to resident's needs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 3 of 16 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 02/22/2024 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure orders for do not resuscitate (DNR) were documented in the physician's orders for 1 of 1 resident (R33) reviewed for advanced directives in the sample of 20. The findings include: On [DATE] at 9:33 AM, R33's electronic medical record was reviewed for advanced directives. R33's POLST (Practitioner Order for Life-Sustaining Treatment) form dated [DATE], located in the miscellaneous section of R33's electronic medical record, showed No CPR (cardio-pulmonary resuscitation). Do not attempt Resuscitation. Selective Treatment: Primary goal is treating medical conditions with limited medical measures. Do Not Intubate or use invasive mechanical ventilation. May use non-invasive forms of positive airway pressure, including CPAP and BIPAP. May use IV fluids, antibiotics, vasopressors, and antiarrhythmics as indicated. Transfer to the hospital if indicated. No information regarding R33's advanced directives for life-sustaining treatment was found in R33's Physician's Orders, or on R33's banner page in her electronic medical record. On [DATE] at 10:40 AM, V3 (Assistant Director of Nursing-ADON) was asked to check R33's electronic medical record, to see if she saw an order regarding R33's DNR or full code status. V3 said she did not see any information on R33's banner page or in her Physician's Orders. V3 was asked for a copy of R33's face sheet with diagnoses and Physician's Orders. At 10:52 AM, V18 (Social Services Director) said when R33 was readmitted to the facility from a local hospital recently, the facility missed entering R33's information regarding her DNR status in her physician's orders. On [DATE] at 11:46 AM, V19 (Registered Nurse-RN) said if a resident goes into cardiac arrest, she will look on the resident's banner page in their electronic medical record to find out if the resident is a full code or a DNR. V19 said if the information is not on the banner page, she would look at the resident's orders. V19 said if she did not see it there, there is a list in the room behind the nurse's station that tells what the residents' status for DNR, or full code is. V19 and this surveyor went to the room behind the nurse's station and V19 said the document was not in there. V19 said the nurse can also check in the resident's electronic medical record under the miscellaneous section for the DNR form. V19 said it is important when a resident is coding (in cardiac arrest), to make sure the information is readily available, and the order is in place; so, the nurse knows whether to start CPR or not. R33's admission Record provided by V3 on [DATE], showed Advanced Directive: DNR, selective treatment. Primary goal of treating medical conditions with selected medical measures. In addition to treatments described in Comfort-Focused Treatment, IV fluids and IV medications (may include antibiotics and vasopressors), as medically appropriate and consistent with patient preference. Do Not Intubate. May consider less invasive airway support (e.g., CPAP, BIPAP). Transfer to hospital, if indicated. Generally, avoid the intensive care unit. R33's Order Summary Report printed [DATE], showed an order entered on [DATE] for DNR with the same selective treatment and primary goal as listed previously on R33's admission Record. On [DATE] at 12:06 PM, V18 (Social Services) said V3 (ADON) entered R33's DNR information into her electronic medical record as this surveyor was talking with them about the information not being in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 4 of 16 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 02/22/2024 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)

F 0578 R33's Physician's Orders, or on her banner page. Level of Harm - Minimal harm or potential for actual harm The facility's [DATE] policy and procedure titled Advance Directives and DNR Policy, showed Advanced Directives: Under state and federal law, people have the right to make decisions regarding health care treatment. This includes their right to determine in advance what life-sustaining treatment will be provided, if any, in the future if they are unable to communicate those desires themselves .Advance directives will be placed in the electronic medical record along with the signed POLST or IDPH Uniform Do Not Resuscitate (DNR) form. There will also be a DNR order placed in the POS (Physician's Orders Sheet) section of the electronic medical record . The policy also showed The Advanced Directive Form should be reviewed when the resident is transferred from one care setting to another, there is a substantial change in the resident's health status or the resident treatment preference changes. This review is dated and signed by the reviewer, and the location is also identified. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 5 of 16 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 02/22/2024 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)

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 ensure a resident with poor trunk control was properly positioned; failed to ensure a resident with CHF (Congestive Heart Failure) was weighed daily; and failed to ensure a dressing was in a place to a non-pressure wound for 2 of 7 residents (R23, R282) in the sample of 20. Residents Affected - Few The findings include: 1. On 2/20/24 at 10:22 AM, R23 was sitting in her wheelchair, in the doorway of her room. R23's upper torso was slumped to the right side of her wheelchair. On 2/21/24 at 9:39 AM, R23 was in her room, sleeping in her wheelchair. R23's wheelchair was positioned along the far side of her bed. The wheels were not locked on the wheelchair. R23 was sound asleep with drool noted on her shirt. R23's body was leaning to the left and forward in the wheelchair. R23 did awaken to name but remained in the slouched position. The surveyor asked R23 if she was comfortable and she replied, Not really. The surveyor attempted to ask follow-up questions and R23 fell back asleep in the stooped position. There were no pillows or cushions in place to assist with proper body alignment. On 2/22/24 at 10:11 AM, R23 was in her room, in her wheelchair at the foot of her bed. R23 was slumped to the right and forward with her head resting on the footboard of her bed. R23 did not respond to verbal stimuli. The surveyor walked to face R23. R23 had a string of drool hanging from her mouth and several wet stains on her chest. R23's right arm was not on the arm rest of the wheelchair but hanging down to her side. R23's right hand was hanging off the seat of the wheelchair and her forearm and right shoulder were contacting the metal part of her wheelchair. At 10:15 AM, V9 (Restorative Aide) entered R23's room and loudly said R23's name and touched her shoulders. R23 slowly replied, What? V9 stated, What are you doing in here. You are leaned to the side and making people think you're not responsive. R23 lifted her head slightly and said I'm just resting. V9 replied, Well, can you sit up? You can't have your head resting on the foot of the bed like this. V9 assisted R23 with sitting up straight in her wheelchair. V9 said R23 has had a functional decline in the last six months. V9 said R23 used to walk with a walker but hasn't been able to ambulate in a while. V9 said R23 had poor trunk control and can't hold herself in a seated position for long. V9 said R23 doesn't currently have any positioning devices, but she would look into that for her. V9 said R23 is always leaning to one side or the other. V9 said R23 had a stroke, and her left side is weak. V9 said R23 leans the left when they attempt transfers but leans to both sides when in a seated position. R23's Facesheet dated 2/22/24 showed diagnoses to include, but not limited to: stroke with left sided weakness; unsteadiness on feet; dysphagia; falls; diabetes; CHF (Congestive Heart Failure), Stage 2 chronic kidney disease; insomnia; muscle spasms; persistent mood disorder; myopathy; obstructive sleep apnea; generalized anxiety disorder; obesity; and major depressive disorder. R23's facility assessment dated [DATE] showed she was cognitively intact; had limited range of motion on one side of her upper and lower extremities; and required substantial to maximal assistance from staff for toileting, showering/bathing, rolling left and right, sitting to lying, lying to sitting on side of bed, and sitting to standing. The surveyor asked for a recent Restorative Assessment. It was not provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 6 of 16 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 02/22/2024 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm On 2/22/24 at 11:18 AM, V3 (Assistant Director of Nursing - ADON) said a resident should be sitting upright when not in bed. V3 said this provides the resident with proper body alignment and ensures their safety when they are in the wheelchair. A positioning policy was requested and not received. Residents Affected - Few R23's facility assessment dated [DATE] showed she was cognitively intact; had limited range of motion on one side of her upper and lower extremities; and required substantial to maximal assistance from staff for toileting, showering/bathing, rolling left and right, sitting to lying, lying to sitting on side of bed, and sitting to standing. R23's Physician Order Sheet dated 2/22/24 showed, CHF: Weigh daily and record every day shift. Weigh at same time daily. R23's Weight Summary was reviewed from 8/24/23 to 2/20/24. This record was missing over 100 daily weight entries. R23's Medication Administration Records were reviewed from 8/24/23 to 2/20/24. This record showed entries for some of the weights missing on the Weight Summary document, however, there were still 33 daily weights missing. The facility was unable to provide documentation to show the 33 missed daily weights had been completed for R23. On 2/22/24 at 10:15 AM, V9 (Restorative Aide) said she doesn't usually get the resident weights, the floor CNAs are usually responsible for the weights. V9 said there is a form at the nurses' station to assist the CNAs with obtaining the appropriate daily, weekly, and monthly weights. V9 said the nurses will usually tell the CNAs if they need a weight. V9 said the nurse enters all the weights, but some CNAs should be able to chart it too. On 2/22/24 at 10:58 AM, V16 (CNA) said during report the nurse will tell the CNAs if there are any weights that need to be done. V16 said they write the weight down and give it to the nurse, but also chart it in the EMR (Electronic Medical Record). On 2/22/24 at 11:00 AM, V15 (Registered Nurse - RN) stated, When I'm working, I tell the CNAs the weights that I need. It does get busy, so I try to help with the weights when I can. The documentation of the weight depends on who takes it. The CNAs can chart the weight. I usually try to check to see if the weight was documented and chart it too. The weights are charted in the vital signs tab or the MAR (Medication Administration Record). The nurse should review the weights to ensure they are being completed and for any possible concerns. Sometimes the weight is totally off, and we need to check if the CNA charted pounds or kilograms. Maybe we need to re-weigh. The daily weights are done for CHF residents to keep an eye on their fluid status. It's helps us track any possible issues. On 2/22/24 at 11:18 AM, V3 (Assistant Director of Nursing - ADON) stated, Residents that have CHF should be daily weights. The doctor would write an order for daily weights. The weight can be charted by the CNA or the nurse and should be in the vital signs section, under weights, or in the MAR. There is nowhere else that the weights would be charted. If the doctor ordered daily weights, then we should be doing daily weights. Daily weights are monitored to watch for a fluid overload in CHF residents. The doctor should be notified if a resident gains more than 3 pounds in a day or 5 pounds in a week. I was actually looking at [R23's] weights last week and noticed that they do fluctuate a lot. The surveyor informed V3 that R23's EMR was missing over 100 daily weights under the vital signs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 7 of 16 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 02/22/2024 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few charting. Then the surveyor compared this to the MARs and R23 was still missing 33 daily weights. V3 replied, Those are the two places the weights should be charted. I wouldn't look anywhere else for them, so they must not have been done. 2. R282's electronic face sheet printed on 2/22/24 showed R282 has diagnosis including but not limited to non-pressure chronic ulcer of left foot, type 2 diabetes with foot ulcer, chronic pulmonary embolism, and fibromyalgia. R282's wound assessment dated [DATE] showed, Diabetic ulcer 1.6x1x0.10cm . serosanguineous drainage. R282's physician's orders dated 2/12/24 showed, Cleanse left foot with normal saline, apply medihoney/therahoney and skin prep to peri-wound. Cover with bordered foam/gauze every 2 days for wound and every 24 hours as needed. On 2/20/24 at 9:47AM, R282 stated, I have a diabetic sore on my left foot. The bandage comes off a lot, but they usually wait for the wound nurse to replace it when she gets here. They will eventually come in and replace it. R282's bandage was wrapped around her left foot (not on her wound). On 2/20/24 at 11:58AM, R282 stated the staff had still not been in to replace her bandage. On 2/21/24 at 8:55AM, R282's bandage was not present on her left foot wound and R282 stated it fell off in the night, but she was told wound care would replace it today. On 2/21/24 at 12:16PM, R282's bandage was still not present to her left foot. On 2/22/24 at 10:06AM, V4 (Registered Nurse) stated, (R282's) dressing is supposed to be on her left foot, we have a PRN (as needed) order for her dressing if it falls off. The aides should tell us when it falls off so we can replace it. If it's not covered then there is an increased risk of infection. She has a diabetic ulcer so it is very important for us to keep it covered and follow the treatment orders so we can try to heal it and it doesn't get worse. On 2/22/24 at 12:08PM, V3 (Assistant Director of Nursing) stated, Residents with wounds should have a dressing on if that is what is ordered. The nurses have a PRN order to replace all dressings and should not be waiting for wound care to come and do the dressing change. If you leave an open wound open to air, you are placing the resident at risk for infection and could possibly worsen the wound. If the aides see that a dressing has come off, they should report it to the nurse right away so it can be replaced. The facility's policy titled, Wound Prevention and Healing dated 6/1/23 showed, Policy Statement: To provide wound care treatment/services (using a multidisciplinary approach) based on evidence-based standards of care under the direction of a physician .9. Continued/Ongoing Treatment. a. Nurse/therapist will provide wound care per physician orders and to continue to implement and evaluate the plan of care based on the effectiveness of treatment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 8 of 16 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 02/22/2024 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on interview and record review the facility failed to ensure a resident's restorative program of passive range of motion to upper and lower extremities was being provided daily for 1 of 3 residents (R2) reviewed for restorative services in the sample of 20. The findings include: On 2/21/24 at 09:35 AM, R2 was sitting up in bed with the head of her bed elevated. R2 was wearing a hospital type gown and her hands were deformed. R2 stated, I am also not getting restorative. It is only being done once per week usually, sometimes twice a week. I should be getting it three times per week. I was on therapy and that stopped in December and restorative was supposed to start then. I fractured my left arm in April and can't do range of motion on my own to that arm. I need help with the movement to that arm, so it doesn't get more stiff. There are no set days for the three times per week. It is really supposed to be done 5 days per week. There is supposed to be two girls doing restorative and I have only seen one. I keep getting told that they are going to set up restorative for me, but it hasn't happened. When I do get ROM (range of motion) done twice a week the girl said she can tell the difference because I am less stiff. I have RA (rheumatoid arthritis) and I can do some ROM to my hands on my own. They are supposed to do upper and lower ROM on me. The last time I had ROM was yesterday and she said she wouldn't be here the rest of week. V10 is the restorative aide; the only one I have seen. R2 stated V9 (Restorative Aide) is at the facility 3 days per week and V10 is there 2 days per week. R2 stated she has never seen V9. The Face Sheet dated 2/21/24 for R2 showed medical diagnoses including rheumatoid arthritis, muscle weakness, osteoporosis, anemia, hypothyroidism, hyperlipidemia, gastro-esophageal reflux disease, and personal history of healed traumatic fracture. The MDS (Minimum Data Set) dated 11/23/23 for R4 showed no cognitive impairment; dependent on staff for eating, hygiene, dressing, bed mobility, and transfers. The Care Plan dated 12/8/23 for R2 showed Restorative: Impaired mobility due to decreased ROM related to arthritis, weakness, and deconditioning. Resident will partake in PROM (passive range of motion) to BUE/BLE (bilateral upper extremities/bilateral lower extremities) with caregiver assist. Do not move or force joint beyond resident is able to or if causes pain, stop. Give enough time for resident to complete task. The Task Description documentation for R2 dated 2/22/24 showed Restorative: PROM: Passive range of motion to bilateral upper extremities/bilateral lower extremities x 10 repetitions. At least 15 minutes daily. The Task documentation had a revision date of 11/30/23 and no resolved date. On 2/21/24 at 12:31 PM, V10 (Restorative Aide) stated she works 4 days a week with 3 of those days as the restorative aide. V10 stated V9 (Restorative Aide) works the two days of the week she is not here as the restorative aide. V10 stated every resident has some type of restorative plan. V10 stated residents usually have two restorative plans on their care plan and she assists V13 (Restorative Nurse) with the restorative plans. V10 stated some residents may have a walking plan, upper body exercises, lower body exercises; it just depends on what the resident can do. V10 stated residents are supposed to get restorative twice per week and there is only one person per day providing restorative programs. V10 stated the CNA's helping residents with transfers and dressing is part of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 9 of 16 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 02/22/2024 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's restorative programs. V10 stated it should be documented daily by the CNA's as well as restorative aides under tasks. V10 stated they have to type how many minutes a day is spent on restorative. V10 stated R2 should have restorative PROM done twice per week. V10 stated, R2 is one that asks for it every day but with the amount of patients it can't be done every day. R2 said she gets stiff. I didn't know she is a daily one; I didn't think we had anyone on daily restorative programs. The CNA's do something daily with them and should be documenting it. We do it above what they do. On 2/21/24 at 12:43 PM, V8 CNA stated restorative programs are done by restorative CNA's. V8 stated the CNAs don't do them. V8 stated that they will document under restorative for dressing etc. because that is on there. V8 stated the CNAs don't provide PROM. On 2/21/24 at 12:53 PM, V3 ADON (Assistant Director of Nursing) stated the restorative nurse was not at the facility today. V3 stated restorative programs including PROM is done 5-6 days per week at 15 min intervals. V3 stated they have two restorative aides that help the restorative nurse. V3 stated a variety of programs including dressing, grooming, walk to dine, and ROM/PROM (range of motion/passive range of motion) are provided for residents. The restorative nurse and restorative aides are responsible for PROM. V3 stated R2 should receive restorative services for stiffness in muscle, prevent contractures, and to keep limbs moving. V3 stated it is important for R2 to receive restorative programs/services. The facility's Restorative Nursing Program policy (6/16/2022) showed, it is the policy of the facility to assist each resident to attain and or maintain their individual highest most practical functional level of independence and well-being, in accordance to State and Federal Regulations. Each resident will be screened and evaluated by the nurse designated to oversee the restorative nursing process for inclusion into appropriate facility restorative nursing program(s) when it has been identified by the interdisciplinary team that the resident is in need or may benefit from such program(s). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 10 of 16 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 02/22/2024 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on interview and record review the facility failed to provide indwelling urinary catheter care for 1 of 3 residents (R40) reviewed for catheters in the sample of 20. Residents Affected - Few The findings include: On 2/20/24 at 10:03 AM, R40 was sitting in bed with the head of his bed raised. R40 had an indwelling urinary catheter with the drainage bag attached to the lower part of the bed. R40 had chunks of white sediment in his catheter tubing and drainage bag. R40 stated staff do not provide catheter care such as cleaning his penis and catheter tubing. Catheter care for a male resident was discussed with R40 and he stated, They don't do any of that. On 2/21/24 at 2:10 PM, V3 ADON (Assistant Director of Nursing) stated catheter care is provided with any incontinence episode of stool and every shift for sure. V3 stated staff should clean the urethral meatus so a resident doesn't develop an infection and empty the drainage bag so there is no backflow of urine, and this should be done every shift. V3 stated there should be CNA task documentation and perineal care/catheter care should be part of the documentation. V3 stated the CNAs know to do this every shift. When emptying the drainage bag would be the opportune moment to provide catheter care/cleaning. On 2/21/24 at 2:27 PM, V3 ADON (Assistant Director of Nursing) went to R40's room; V12 (R40's wife) was at his bedside. R40 stated they did not do any catheter care today. R40 stated he did get his catheter changed this morning at 5:00 AM. R40 was having abdominal pain and back pain; felt awful and could not urinate. They couldn't get his catheter irrigated so it was changed by the nurse. V3 confirmed she was aware R40's catheter had been changed that morning. On 2/21/24 at 2:49 PM, V7 CNA stated catheter care is done when a resident has a bowel movement and when she empties the drainage bag. V7 stated when she provides catheter care she will close the curtain. If it is a male, she will pull the skin back and clean the penis. V7 stated she will then clean the catheter tubing in a motion away from the resident. The Face Sheet dated 2/21/24 for R40 showed medical diagnoses including multisystem degeneration of the autonomic nervous system, left side hemiparesis and hemiplegia following cerebral infarction, dysphagia, dysarthria, benign prostatic hyperplasia, neuromuscular dysfunction of the bladder, hypertension, and hyperlipidemia. The Physician Orders dated 2/21/24 for R40 showed: Reinsert new 20 French, 30 cc urinary catheter monthly and as needed; Indwelling Urinary Catheter Care: Catheter Care considered part of routine care/peri care. No order required. No documentation required. The Physician's Note dated 1/13/24 for R40 showed, Past medical history includes .neurogenic bladder with Supra-Pubic Catheter that was later discontinued and indwelling urinary catheter placed. Urinary Comments: Indwelling urinary catheter with sediment. Neurological Comments: Alert and oriented x person, place and situation; patient is slow to respond to questions asked but is appropriate with his responses. Chronic indwelling urinary catheter- catheter to be flushed daily; no output concerns reported. Benign prostatic hypertrophy - continue with urinary catheter; staff to assist with peri care to help keep skin clean and dry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 11 of 16 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 02/22/2024 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The Care Plan dated 12/28/23 for R40 showed, the resident has an indwelling suprapubic and urinary catheter related to neurogenic bladder. Catheter: The resident has a 16 French indwelling catheter and 18 French suprapubic catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Monitor/document for pain/discomfort due to catheter. Monitor for signs and symptoms of discomfort on urination and frequency. Monitor/record/report to medical doctor for signs/symptoms of UTI (urinary tract infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating pattern. The care plan did not show what catheter care was to be provided or the frequency. The facility's Perineal Care/Indwelling Catheter policy (6/13/22) showed, perineal care is done daily and as needed for all residents requiring assistance and/or those residents with an urinary catheter. Wash perineal area and around the catheter (if applicable) with periwash and water using a washcloth. If appropriate, rinse with warm water. For males, retract foreskin if present, wash, dry and replace foreskin. Ensure catheter is positioned correctly and secured. Wipe down tubing using downward stroke with clean cloth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 12 of 16 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 02/22/2024 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)

F 0880 Provide and implement an infection prevention and control program. 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 implement contact precautions to alert staff and visitors of a resident with an active infection, failed to ensure catheter care was provided in a manner to prevent cross-contamination for a resident with an active infection, and failed to ensure supplies used for personal cares were not contaminated. The facility also failed to ensure staff wore PPE (personal protection equipment) when performing wound care for a resident on enhanced barrier precautions. This applies to 2 of 8 residents (R67, R44) reviewed for infection control in the sample of 20. Residents Affected - Few The findings include: 1. R67's admission Record, provided by the facility on 2/22/24, showed he was admitted with diagnoses including hemiplegia (paralysis affecting one side of the body), malignant neoplasm of bronchus or lung, secondary malignant neoplasm of brain, chronic kidney disease stage 4 (severe), an extracorporeal (wide-bore central venous line) dialysis catheter, urinary tract infection, and encounter for surgical aftercare following surgery on the digestive system, R67's care plans showed he had an indwelling urinary catheter related to urine retention and a colostomy due to a prior diagnoses of necrotic (non-viable) intestinal loops. R67's care plans showed he required assistance due to an ADL (activities of daily living) self-care deficit related to decreased muscle coordination and strength due to a prolonged hospital stay and a diagnosis of hemiplegia with left-sided weakness. R67's facility assessment dated [DATE], showed he was cognitively intact. On 2/20/24 at 10:40 AM, R67 was lying in bed in his room. A sign on the outside of R67's room, showed he was on Enhanced Barrier Precautions. R67 was alert and oriented. A urinary drainage bag was hanging on the side of R67's bed. R67 said he always has an infection in his urine. On 2/20/24 at 12:49 PM, R67 was in his room, lying in bed. Two family members were in R67's room. V20 (R67's family member) pointed to a package of wet wipes on the dresser next to R67's bed and said This is what they use to clean him with. There is feces all over it. The wet wipes package had several areas containing a brown substance all around the opening and sides of the package. V20 said it has been like that for days. On 2/20/24 at 1:33 PM, V17 (Certified Nursing Assistant/Wound Tech) was performing catheter care for R67. V17 used wet wipes to clean R67's meatus, then continued wiping from R67's penis to the catheter tubing, down the tube, in one swipe. V17 repeated this same technique three more times. V17 did not remove the gloves used to clean R67. V17 secured the sides of R67's incontinent brief, pulled up his pants, then pulled the blanket up and covered R67 to his shoulders. V17 moved the package of wipes and the box of gloves to the end of R67's bed, using the same soiled gloves. V17 removed the gloves used for catheter care and touched the curtain to move it to go over to the sink to wash her hands. V17 put clean gloves on and emptied R67's urinary drainage catheter bag. The bag had 100 cubic centimeters (cc) of a tannish/brown liquid in it. V17 removed the gloves and washed her hands. V17 picked up the package of wipes and the box of gloves and carried them over by the sink and placed them on the counter. On 2/21/24 at 11:06 AM, a sign on R67's door now says Contact Isolation. V17 (CNA/wound tech) said yesterday the sign said Enhanced Barrier Precautions and today it says Contact Precautions. V17 said she did not know why R67 was changed to Contact Isolation. The soiled package of wet wipes was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 13 of 16 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 02/22/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few still sitting on R67's dresser. The package was still visibly soiled with several areas of a brown substance around the opening and sides of the package. The package appeared less full, with about half of what was in there the previous day. R67 said the facility staff have been using the wipes on him. On 2/21/24 at 12:09 PM, V3 (Assistant Director of Nursing-ADON) said R67 was started on Contact Isolation last night (2/20/24). V3 said originally, when the nurse on duty relayed the lab results to her (V3), she was told it was just a UTI (urinary tract infection). V3 said she was looking through the lab results on 2/20/24 and checking to see what antibiotic was prescribed. V3 said she saw R67's infection was VRE (Vancomycin-Resistant Enterococcus) and changed R67 from Enhanced Barrier Precautions to Contact Isolation. V3 said it should have been caught right away when the culture and sensitivity came back. It is important because we want to make sure we are protecting everyone in the building, including the visitors that come in. V3 said they (the facility) also want to make sure R67 is on the proper antibiotic. At 12:14 PM, V3 said the urinalysis results were received on 2/16/24. I believe a different nurse received the order for the antibiotic on 2/17/24 and it was started on 2/18/24 at 9:00 AM. V3 said that is not normal to start an antibiotic 2 days after the results are received. On 2/22/24 at 11:02 AM, V3 (Assistant Director of Nursing-ADON) said she would expect staff to use a different wipe to clean the meatus and the catheter tubing for infection control to prevent introducing bacteria into the resident's body. The CNA should have removed her gloves and washed her hands before touching the resident, their clothes or blankets to prevent cross-contamination. V3 said the soiled package of wipes should have been thrown away and a new one used because it was soiled. V3 said the nurse that worked on 2/16/24 should have notified the doctor or Nurse Practitioner about the infection, to get new orders. V3 said the nurse working on 2/16/24 should have informed the pharmacy right away so the antibiotic could be started as soon as possible; to treat the infection. R67's Urinalysis Culture Lab Result Report, provided by the facility on 2/22/24, showed the culture results were reported to the facility on 2/16/24 at 4:02 PM. The report showed Enterococcus faecuim VRE 50,000-100,000 colonies/ml (colonies per milliliter). The report showed Vancomycin resistant enterococci (VRE) are multi-drug resistant strains and their occurrence should be closely monitored. Another report from the same lab showed the results were reported to the facility on 2/16/24 at 4:16 PM. R67's progress notes showed on 2/17/2024 at 8:36 PM an entry was made showing a telephone call was made to (Medical Group). Spoke to Nurse Practitioner (NP) regarding patient is positive for UTI. The note showed the NP gave an order for an antibiotic for 14 days. R67's Order Summary Report, provided by the facility on 2/22/24, showed an order to maintain Contact Precautions/Isolation for VRE in urine was received on 2/20/24 (four days after the lab results showing VRE were received). R67's February 2024 electronic Medication Administration Record (EMAR) showed an antibiotic was started on 2/18/24. R67's February 2024 electronic Treatment Administration Record (ETAR) showed Contact Isolation was started on 2/20/24 at 11:00 PM. The facility's 7/20/2020 policy and procedure titled Physician and POA (Power of Attorney) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 14 of 16 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 02/22/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notification showed Guideline .2. In a non-emergent, but acute medical situation (including critical lab values and other diagnostic test results) the physician will be paged and if there is no return (call), the physician will be notified again. Medical Director may be called as necessary. The facility's 11/23/2021 policy and procedure titled Isolation-Categories of Transmission-Based Precautions showed 2. Transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person .1. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC (Centers for Disease Control) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. 2. When transmission-based precautions are in effect, non-critical resident care equipment items such as a stethoscope, sphygmomanometer, or digital thermometer will be dedicated to a single resident (or cohort of residents) when possible. a. If re-use of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with another resident .Contact Precautions: 1. Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. 2. On 2/22/24 at 10:02 AM, V14 (Registered Nurse - RN) was gathering supplies from the treatment cart. V14 said she was going to change R44's drain appliance because it was leaking. R44's door had an Enhanced Barrier Precaution sign posted on it. R44 was sitting up in his wheelchair. V14 entered R44's room and explained that she was going to change the bag, and asked R44 to get in the bed. R44 self-transferred from the wheelchair to the bed and pulled his shorts and incontinence brief down slightly. The top, inner band of R44's incontinence brief was stained with light brown, yellow drainage. R44 had several paper towels wadded up and tucked under an ostomy appliance bag. V14 washed her hands and applied clean gloves but did not apply a gown. V14 continued to remove the old ostomy bag and dressing, exposing a pink moist opening on R44's left lower quadrant. R14's skin under the ostomy appliance and into his left groin was excoriated with a white paste noted. V14 said R14 has a lot of issues with the appliance leaking and sometimes his skin will break down because of it. V14 changed gloves, cleansed around R14's wound, applied skin prep, and then place a clean wafer and ostomy appliance (bag) to R14's left abdominal wound. V14's scrubs were in contact with R14's bed when she was performing the wound care. V14 did not wear a gown throughout the wound care. R44's Face Sheet printed 2/22/24 showed diagnoses to include, but not limited to: encounter for change or removal of drains; psoas muscle abscess; peripheral vascular disease; Stage 3 chronic kidney disease; edema, dementia, anxiety disorder, major depressive disorder, and long-term use of antibiotics. R44's Physician Order Sheet dated 2/22/24 showed to check ostomy every shift for leaking and Enhanced Barrier Precautions (EBP). This document also showed PPE should be worn for high contact activities including: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care, or wound care (any skin opening requiring a dressing). R44's Care Plan initiated 2/20/24 showed he was on Enhanced Barrier Precautions related to R44's stoma (opening in the abdominal wall). The intervention showed, Wear gloves and a gown for High Contact Resident Care Activities . Wound Care: any skin opening requiring a dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 15 of 16 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 02/22/2024 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The sign posted on R44's door showed: Enhanced Barrier Precautions: STOP! EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities . Wound Care: any skin opening requiring a dressing. On 2/22/24 at 11:18 AM, V3 (Infection Preventionist) said EBP are in place to protect the residents from us. V3 said residents are placed on EBP because they have a portal of entry (for microorganisms) into their body somewhere. V3 said the nurse should have worn a gown and gloves to provide wound care to R44. V3 said R44 was on EBP due to his open drain site. V3 said R44 used to have a JP drain in that area, but it was removed and now the facility applies an ostomy appliance to collect drainage from that site. V3 said R44 had an abscess in that area and is on long-term antibiotics for that issue. The facility's Enhanced Barrier Precautions Policy reviewed 10/23 showed, Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. aureus and Multidrug Resistant Organisms (MDRO). EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status; Infection or colonization with an MDRO . Examples of High Contact Resident Care Activities: .device care or use; and wound care: any skin opening requiring a dressing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 16 of 16