Inspection·September 18, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 4. The facility provided a list for Covid 19 residents and show R1 and R2 were positive for Covid 19. Residents Affected - Some R1 and R2's room was closed with a sign of droplet and contact precaution. A cart of PPE was available by the door. On 9/18/24 at 9AM, V4 (CNA) was entering R1 and R2's room. V4 was wearing gown, gloves, face shield, surgical mask then N95 mask over the surgical mask. On 9/18/24 at 9:25 AM V2 (DON) and V3 (ADON/Infection Control) both said all staff have been in serviced last Monday 9/16 regarding Covid 19 isolation, PPE to use including gown, gloves, face shield and N95 mask. Staff have the option to apply surgical mask over the N95 mask but, not under N95 mask as it may compromise the seal of the N95 mask. Both V2 and V3 also said the PPE are one use, staff should doff when leaving the room then apply a new set of PPE, gown, gloves, N95 mask and face shield prior to entering another residents room. The facility policy entitled Covid 19 Guidance dated 10/20/2021 show, a. If a resident is suspected or confirmed to have Covid 19, staff will wear N95 respirator, eye protection, gown and gloves. \ Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when entering COVID-19 isolation rooms and for resident rooms that were on isolation for suspected/ruling out COVID-19. The facility also failed to ensure staff disposed of a face shield after use and failed to ensure staff did not wear surgical masks under N95 masks. This applies to 7 of 9 residents (R1, R2, R3, R4, R7, R8, and R9) reviewed for infection control in the sample of 9. The findings include: 1. On 9/18/24 at 8:37 AM, V7 (Certified Nursing Assistant- CNA) entered R3 and R4's room. On the outside of R3 and R4's room were signs indicating R3 and R4 were on droplet and contact isolation. The signs indicated eye protection was required to enter the room. V7 placed on PPE before entering the room; however, V7 did not have on eye protection when entering the room. V7 also had a black surgical mask on under the N-95 mask. A list provided by the facility indicated R3 and R4 were on isolation for COVID-19. (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 09/18/2024 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)