Inspection·October 10, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few until when the money was alleged to be missing (09/27/2024). V1 added that the video surveillance showed staff were never present in R1's room without R1 and/or her roommate (R2) also present. V1 said there were no findings in the facility's investigation, so the incident was reported to public health and a police report was filed with the local department which they have not received to date. V1 (Administrator) and V3 (Social Services Director) both said that they believed R1's son took the money because they couldn't prove staff took the money and R1's son became defensive when confronted. When asked if the facility could provide evidence that a staff member did not take R1's money, V1 responded no. V1 (Administrator) provided documentation of her request to reimburse or credit R1 for the missing money that has not been provided to R1 as of current. On 10/10/2024 at 11:02 AM, V4 (Registered Nurse) said during R1's admission inventory, she asked R1 if she had any money on her person. R1 initially said no but V4 saw a blue purse and handed it to R1. V4 added that R1 took out some bills from the wallet then counted the money which totaled $75. V4 said R1 did not want her to secure the money and indicated that her son would pick it up the following day so R1 put the money back into the wallet. V4 said she wrote a note on R1's inventory sheet indicating the same and reported off to the oncoming nurse about the money and when R1's son would be picking it up. On 10/10/2024 at 11:39 AM, V7 (Certified Nursing Assistant) said he was working when R1 admitted and that V4 was the nurse. V7 added that R1 came with a clear plastic bag from the hospital that contained some personal belongings which he placed in the closet. V7 (Certified Nursing Assistant) then said he informed V4 (Registered Nurse) about the bag. He added that V4 and R1 began going through the bag, then he heard V4 say to R1, oh you have some money. V4 then told R1 that she would record the amount of money on her inventory sheet. V7 said he then left the room shortly after this encounter. On 10/10/2024 at 12:34 PM, V8 (Maintenance Director) said he reviewed video surveillance from R1's admission on [DATE] until the time it was first reported missing on 09/27/24. V8 then said he only saw R1's son enter her room on 09/27/2024 and R1 was present. V8 added there was not a time when he could see on the video that R1's son was in the room alone without either R1 or R2 present. V8 also said that he did not see a time when staff were in the room without one or both residents being present. When asked if activity within the room could be visualized with the video surveillance, V8 said whatever occurred in the room is not visible on the video and that it could have been a staff member because he never saw the son in the room alone. On 10/10/2024 at 1:42 PM, V9 (Agency Registered Nurse) said she doesn't recall R1 specifically but does recall that she has never been informed about any resident at the facility having money on their person and/or that a family member would be picking up the money. On 10/10/2024 at 02:04 PM, V2 (Director of Nursing) said R1 informed her on 09/27/2024 that she had $75 missing. V2 then said R1 gave permission for V2 and V4 (Registered Nurse) to search her room but could not locate the money which V4 verified was present and counted on admission. When asked why the facility waited several days to report the incident to public health and/or the local police, V2 (DON) said R1 didn't allege that the money was stolen until 10/03/2024 and that's when V1 was informed, and a complete investigation was initiated. Prior to this date, R1 just said the money was missing. Reviewed facility's undated abuse prevention program policy that indicated the following: residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 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 145612 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 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 0602 physical or chemical restraint not required to treat the resident's medical symptoms. Level of Harm - Minimal harm or potential for actual harm The purpose of this policy and the abuse prevention program is to describe the process of identification, assessment, and protection of residents from abuse, neglect, misappropriation of property, and exploitation. This will be accomplished by and not limited to: establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. Residents Affected - Few No theft policy was provided by the facility during course of this investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145612 If continuation sheet Page 3 of 3