Inspection·May 28, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review the facility failed to ensure staff safely assisted a resident with repositioning in bed. This applies to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 3. The findings include: On May 28, 2024, at 9:01 AM, R1 was asleep in bed. R1 had two scabs from lacerations in the shape of a V on his forehead. They measured approximately an inch and a half to 2 inches a piece. He also had a scab from another laceration on the top of his head. There were 7 staples that were visible. The laceration measured approximately 10 inches long. R1 was lying on an air mattress. There were no side rails on the bed or anything for R1 to hold on to when he rolled over. R1 was also a very large man. The bed had an extender on it for length because he appeared to be over 6 feet tall. The left side of the bed had a nightstand, and the right side of the bed had a closet. R1's arms were wrapped with a gauze dressing and very swollen with fluid. R1's electronic medical record shows, he is on hospice and bed bound (he has not been out of bed for a few weeks). R1's witnessed fall incident report dated May 23, 2024, shows, Incident description: Nursing description: whilst [SIC (statement is correct)] in another room writer heard CNA (certified nursing assistant) saying not to roll too far. writer went to where CNA wss (was [SIC]) assisting patient. writer observed patient face down on the right side of his bed with his legs on the bed. Resident Description: pt (patient) said he rolled too far. Immediate action take: Description: Patient kept in place on floor d/t (due to) bleeding from head and mouth . Witnesses: V4 CNA. R1's progress notes dated May 23, 2024, shows, At about 450am writer rushed to pt's room after hearing a sound and staff calling for assistance. Upon arrival writer observed pt off his bed face down on the floor while his legs were still on the bed Pt bleeding from mouth, forehead and head . R1's progress notes dated May 23, 2024, shows, Was asked to see Patient's head upon return from ER (emergency room). Patient stated when he was being turned during brief changing by CNA, I helped them too much and went over the side and hit my face and head. 9 staples present . Abrasion to forehead . Small dry laceration to left temple. R1's after visit summary from local emergency room visit dated May 23, 2024, shows, Today's Visit: Reason for visit: fall, closed head injury, scalp laceration. Diagnoses: cut on skin on top or back of head, contusion of scalp. (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 3 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 05/28/2024 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)