Inspection visit
Inspection
17 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 17 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
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 who is morbidly obese
received the appropriate wheelchair for 1 of 18 residents (R128) reviewed for accommodation of needs in
the sample of 18.
Residents Affected - Few
The findings include:
R128's face sheet printed on 3/12/25 shows R128 was admitted to the facility on [DATE] with a diagnosis
that include fracture of left lower leg wearing a cast and morbid (severe), obesity due to excess calorie, and
congestive heart failure (CHF) on oxygen.
On 3/10/25 at 9:16 AM, V9 and V10 both Certified Nursing Assistants (CNA) were transferring R128 to her
wheelchair via a mechanical lift. As R128 was being lowered and placed into the wheelchair, R128 was not
positioned well in the wheelchair. V9 and V10 kept on trying to pull R128 back so R128 could fit in the
wheelchair, but R128 was not moving an inch, since there was no space on either sides or back of the
wheelchair. R128's midsection was wider than the wheelchair. R128 stated this is so tight, It's
uncomfortable. R128 was trying to use her casted leg to push herself in the wheelchair. V9 and V10 were
holding unto R128 so as not to slide down from the wheelchair. V9 and V10 continued trying to position
R128 in the wheelchair. This surveyor had to ask for R128's nurse (V8 Registered Nurse) to come to
R128's room.
On 3/10/25 at 9:30 AM, V8 (RN) was in R128's room. R128 informed V8 she was not comfortable with the
wheelchair. V8 said R128 barely fits in the wheelchair, the wheelchair is too small. R128 cannot sit back
enough in the wheelchair. R128 needs to get back to bed for safety. R128 needs a wider chair.
On 3/10/25 at 10:30 AM, V7 (Restorative Nurse) said the chair that the staff was using to R128 was a
regular wheelchair. R128 should have a bariatric wheelchair. Therapy took R128's chair to ensure it was the
right size of wheelchair. Therapy will provide a wheelchair for R128.
On 3/10/25 at 10:44 AM, V11 (Therapy Director) said R128 needed at least a size 26 wheelchair (bariatric
wheelchair-morbidly obese.) The right size wheelchair can provide comfort, prevent skin conditions and
ensure residents safety.
The facility policy entitled Accommodation of Needs dated 7/23/24 documents, The resident's individual
needs and preferences will be accommodated to the extent possible except when the health and safety of
the individual or other residents would be endangered.
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 9
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
03/12/2025
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** 2. R128's
Face Sheet printed on 3/12/25 show R128 was admitted to the facility on [DATE] with diagnoses that
include congestive heart failure (CHF) and chronic respiratory failure dependence on supplemental oxygen
due to shortness of breath.
Residents Affected - Few
On 3/10/25 at 9:10 AM, R128 was in bed with oxygen on via nasal cannula. R128 said she gets short of
breath easily.
R128's Physician's Order Sheet (POS) shows an order dated 3/5/25 for daily weights for a diagnosis of
CHF. Notify Cardiologist/Primary MD/NP If weight increases by 3 pounds (lbs) in 1 day or 5 lbs in 1 week.
The same POS shows another renewal order date of 3/10/25 for weight daily and record.
R128's Weights and Vitals summary printed on 3/11/25 shows that between 3/5/26 (admission day) to
3/11/25, R128 did not receive a weight on 3/5, 3/6, 3/8, 3/9, and 3/10.
On 3/11/24 at 12:30 PM, V2 (Director of Nursing) said residents with CHF should be weighed as ordered to
assess for weight gain or fluid overload due to heart failure that can cause shortness of breath and
complications.
Based on observation, interview, and record review the facility failed to obtain treatment orders for a
non-pressure wound and failed to obtain daily weights as ordered for a resident with congestive heart
failure. This applies to 2 of 18 residents (R177 and R128) reviewed for quality of care in the sample of 18.
The findings include:
1. On 03/10/25 at 10:14 AM, R177 was in bed. R177 had a tan foam dressing to her left forearm. The
dressing was not dated. The dressing had shadow drainage that was smaller than a dime. The corners of
the dressing were rolled up.
On 03/11/25 at 10:18 AM, R177 had a different white dressing to her left forearm. The dressing had shadow
drainage that was smaller than a dime.
R177's Progress Note dated 03/08/25 showed R177 had a fall and two skin tears to her left forearm were
found. One skin tear was 5-6 centimeters (cm), and the other was 3-4 centimeters. The same note showed
the skin was cleaned and a dressing was applied.
R177's Order Summary Report printed on 3/10/25 did not show a dressing/treatment order for R177's left
forearm.
On 03/11/25 at 10:54 AM, V6 (Wound Care Nurse) said she was not aware/informed R177 had a wound to
her left forearm. V6 said the last time she saw R177 was on 3/6/25 and R177 did not have any skin tears to
her left forearm. V6 said when a wound is found staff should obtain treatment orders. V6 said for a resident
with a new wound she should be notified. V6 added she would assess the resident/wound to make
treatment recommendations.
R177's Skin/Wound Note dated 03/06/25 did not indicate R177 had skin tears to her left forearm.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145612
If continuation sheet
Page 2 of 9
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
03/12/2025
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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
R177's Wound Assessment Detail Report dated 03/11/25 showed R177 had two skin tears to her left
forearm. One skin tear measured 3 cm x 4.5 cm x 0.2 cm. The second skin tear measured 2.5 cm x 2 cm x
0.10 cm. The document indicated the wounds were facility acquired and identified on 3/11/25.
The facility's Wound Prevention and Healing policy dated 10/9/21 showed wound care treatments are
provided within an individualized plan of care under the direction of a physician.
Event ID:
Facility ID:
145612
If continuation sheet
Page 3 of 9
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
03/12/2025
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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 put interventions in place for residents with
pressure injuries to 3 of 8 residents (R127, R62, and R44) reviewed for pressure injuries in the sample of
18
Residents Affected - Few
The findings include:
1. R127's Physician Order Sheet (POS) printed on 3/10/25 show R127 has an order of LAL (lo air loss
mattress) due to R127 being admitted to the facility with a stage 4 sacral area pressure injury with possible
infection. The same POS show R127's wound treatment for the Stage 4 sacral wound included cleaning
with skin prep peri wound. Apply Therahoney and lightly pack with Alginate tucked to tunnel and depth of
wound. Cover with bordered foam.
R127's wound assessment dated [DATE] show, pressure injury present on admission Stage 4 measuring
3.20 centimeters (cm) x 3 cm x 1.5 cm with undermining of 12 o'clock to 12 o'clock (2.60 cm)
On 03/10/25 at 11:30 AM, R127 was in bed. R127 stated I am soaked and wet, I am lying on these wet
sheets and my back is sore, I have been needing to be changed and turned. R127 was on a regular
mattress. V8 (Registered Nurse-RN) who was in the room to provide incontinence care said R127 was
admitted with a stage 4 pressure injury. V8 (RN) confirmed that R127 was on a regular mattress.
On 3/10/25 at 12PM, V6 (Wound Nurse) who just completed a wound treatment to R127 said R127 was
sent to the hospital due to seizures last Friday afternoon, (3/7/25). R127 was readmitted back to the facility
Saturday afternoon (3/8/25). R127 was moved to another room that day (Saturday 3/8/25). R127 has a
stage 4 wound. R127 needs the lo air loss mattress. This makes me upset. She should have been moved
with her lo air loss mattress.
R127's careplan dated 3/4/35 shows R127 has a pressure injury to her sacrum related to impaired mobility,
incontinence and fragile skin. R127 requires pressure relieving surfaces to bed and wheelchair.
2. On 3/10/25 at 9:39 AM, R62 was lying in bed asleep, both of his heels were resting against the mattress
with no offloading. A green padded heel protector boot was sitting on his bedside across the room. R62
said he has a wound on his foot and cannot wait to get it healed so he can get out of here. On 3/10/25 at
12:15 PM, R62 was still lying in the same position with no heel protectors on and heels were not offloaded.
R62's 3/4/25 Wound Assessment Details Report, shows he has a 1.40 centimeter (cm) x 1.70 cm. x 0.20
cm. stage 4 pressure injury to his right lateral foot. The report shows the current treatment plan is to wear
heel protector boot in bed, and states, always when in bed.
On 03/11/25 at 11:09 AM, V6 (Wound Care Nurse) said R62 should have heel (boot) protectors on when in
bed and he has a pressure injury to his right foot. V6 said staff should be applying the heel boots and R62
generally does not refuse to wear them.
R62's Pressure Injury Care Plan initiated on 10/7/2024, shows he requires pressure relieving devices and
offloading while in bed. R62's pressure injury Care Plan does not address any refusals from
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145612
If continuation sheet
Page 4 of 9
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
03/12/2025
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 0686
R62 for applying heel protector boots.
Level of Harm - Minimal harm
or potential for actual harm
3. On 3/10/25 at 9:25 AM, R44 was lying in bed, both of her heels were resting against the mattress. Her
heels were not offloaded and there were no heel protectors seen at her bedside.
Residents Affected - Few
R44's 3/4/25 Wound Assessment Details Report shows she has the following wounds:
1. A stage 3 pressure area measuring 1.90 x 1.50 x 0.30 cm. to her left heel.
2. A 3.10 cm. x 3.10 cm. x unknown unstageable pressure injury to her right heel. The plan of care identified
for R44's heel show she should have her heels offloaded with heel boots when in bed.
3. A 5.80 cm. x 7.80 cm. x 3.00 cm. stage 4 pressure injury to her sacrum.
R44's Pressure Injury Care Plan initiated on 1/23/25, shows R44 should have weight shifted and her heels
offloaded. The Care Plan does not address any refusals from R44 for offloading or applying heel protectors.
On 3/11/25 at 11:12 AM, V6 said offloading should be done when R44 is in bed.
The facility provided Wound Prevention and Healing policy reviewed on 6/1/24 shows that residents will
have interventions in place to prevent the development of pressure injuries.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145612
If continuation sheet
Page 5 of 9
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
03/12/2025
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 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to implement a care plan intervention for a resident at risk for
malnutrition for 1 of 3 residents (R73) reviewed for nutrition in the sample of 18.
Residents Affected - Few
The findings include:
R73's face sheet shows she is a [AGE] year-old female who was admitted to the facility on [DATE] with
diagnoses including: pressure ulcer of the sacral region, ascites, generalized edema, chronic kidney
disease stage 4, unspecified severe protein-calorie malnutrition and history of gastric bypass surgery.
R73's Nutrition Care Plan initiated on 2/12/25 shows she has the potential for nutritional problems and is at
risk for malnutrition. Interventions for R73 identified in the Care Plan shows weights should be monitored as
ordered.
R73's Physician Order Summary shows an order for weight on day one (admission day) and day two then
weight weekly for 4 weeks (record in the morning every Tuesday for 4 weeks.)
R73's Weight Summary and Medication Administration Record both show R73 was weighed on 2/14/25
and not again until 3/3/25 (17 days later).
On 3/12/25 at 9:00 AM, V12 (Dietician) said she was aware that R73 had lost weight when she ran a weight
report on 3/4/25. V12 said R73 should have had weekly weights at minimum. V12 said that the nursing staff
at the facility does not always notify her of weight loss immediately so she runs a weekly report herself. V12
said while it was expected R73 would lose some weight due to her overall medical conditions, but the
weights should be done to identify weight loss sooner.
On 3/12/25 at 8:50 AM, R73 was eating breakfast in her room. R73 said she only remembers the staff
weighing her one time shortly after admission by a mechanical lift, but she never refused to be weighed
with the lift. R73 said standing was an issue shortly after admission but the lift wasn't a problem, and she
would let them weigh her.
The facility provided Weight Management policy last reviewed on 8/20/24 shows that all residents will be
weighed according to facility policy on admission day, on day two, and weekly for 4 weeks. The policy also
says that weights should be documented in the resident's electronic medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145612
If continuation sheet
Page 6 of 9
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
03/12/2025
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview and record review the facility failed to ensure the menu was followed to
meet the nutritional needs of residents on a pureed diet for 4 of 4 residents (R13, R49, R54 and R65)
reviewed for menus and nutritional adequacy in the sample of 18.
The findings include:
The undated facility provided list of residents on a pureed diet shows that R13, R49, R54 and R65 are all
on a pureed diet.
The Menu Extension Sheet for 3/10/25 shows that residents on a regular diet were to receive sloppy joe on
a bun, cucumber and tomato salad, french fries and mixed fruit for the noon meal. Residents on a pureed
diet were to receive pureed #6 (5 1/3 ounces (oz)) scoop of sloppy joe, tomato juice 4 oz, #8 (4 oz) scoop
mashed potatoes and pureed #8 scoop of mixed fruit.
On 3/10/25 at 10:00 AM, the pureed sloppy joe was made for the residents on a pureed diet. Meat,
thickening powder and water were added to the blender and processed. No bread serving was added to the
meat.
On 3/10/25 at 11:45 AM, R13, R49, R54 and R65's noon meal was plated. A #8 (4 oz) scoop of the pureed
sloppy joe meat was provided. There was no additional bread serving provided.
During continuous dining observations on 3/10/25 between 12:30 and 1:22 PM, R13, R49, R54 and R65
were not served pureed mixed fruit. By 1:22 PM, R13, R49, R54 and R65 all had exited the dining room.
The Menu Extension for 3/11/25 shows that regular diet residents are to get strawberry jello cake. The
sheet shows that pureed diet residents are to get pureed #10 scoop of strawberry jello cake.
On 3/11/25 at 12:43 PM, R13, R49, R54 and R65 were in the dining room eating the noon meal. R13, R49,
R54 and R65 did not have pureed strawberry jello cake present.
On 3/11/25 at 2:17 PM, V15 (Dietary Manager) said that he used a #8 scoop for the pureed sloppy joe
because he thought that is what the sheet said to use. V15 said that he did not serve the pureed diet
residents any bread serving with the sloppy joe meat. V15 said that he did not serve the pureed diet
residents pureed mixed fruit because he forgot since he was busy training someone. V15 said that he did
not serve pureed strawberry jello cake to the residents because he read the sheet wrong.
On 3/11/25 at 2:00 PM, V12 (Dietitian) said that the menus should be followed, and the spreadsheets
should be followed using the appropriate scoop sizes to ensure each resident gets a balanced diet.
The facility's Portion Control Chart shows that a #6 scoop is 5 1/3 oz, a #8 scoop is 4 oz, and a #10 scoop
is 3 oz.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145612
If continuation sheet
Page 7 of 9
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
03/12/2025
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
Based on observation, interview, and record review the facility failed to ensure staff wore the required
personal protective equipment (PPE) for a resident on enhanced barrier precautions for 1 of 18 residents
(R178) reviewed for infection control in the sample of 18.
Residents Affected - Few
The findings include:
R178's Order Summary Report printed on 3/11/25 showed R178 had an order to be on enhanced barrier
precautions due to a wound and another order for PPE to be used during high contact resident care
activities such as transferring the resident. The orders had a start date of 3/8/25.
On 03/10/25 at 10:26 AM, V3 (Infection Control Nurse) put a sign on R178's door indicating R178 was on
enhanced barrier precautions. V4 (Occupational Therapist) and V5 (Physical Therapist) were in R178's
room assisting R178 to stand, walk across the room, and sit in a chair. V5 supported R178 to transfer by
holding onto a gait belt. V4 and V5 had on gloves. V4 and V5 did not have on a gown.
On 03/10/25 at 10:48 AM, V3 was asked what triggered her to place an enhanced barrier precaution sign
on R179's door. V3 said R178 was a newer admission, and she just became aware of his wound.
On 03/11/25 at 10:12 AM, V3 said for a resident on enhanced barrier precautions staff should wear gloves
and gowns when assisting the resident to transfer.
R178's Care Plan with an initiated date of 3/2/25 showed R178 was on enhanced barrier precautions due
to a wound. Listed under interventions was for staff to wear gloves and gown for high contact resident care
activities such as transfers.
The facility's Enhanced Barrier Precautions policy with a revision date of 3/28/24 showed enhanced barrier
precautions is an approach to targeted gown and glove use during high contact resident care activities. The
policy listed transferring as a high contact resident care activity.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145612
If continuation sheet
Page 8 of 9
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
03/12/2025
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure a resident received a pneumococcal vaccine for 1 of
5 residents (R52) reviewed for immunizations in the sample of 18.
Residents Affected - Few
The findings include:
R52's Face Sheet shows that she is [AGE] years old and admitted to the facility on [DATE] with diagnoses
of: end stage renal disease, dialysis, chronic obstructive pulmonary disease, chronic respiratory failure with
hypoxia, congestive heart failure, dependence on supplemental oxygen and obstructive sleep apnea.
R52's Pneumococcal Vaccine Consent form dated 10/14/24 shows that she gave consent to receive the
pneumococcal vaccine.
R52's Immunization Report printed 3/10/25 shows that she received a pneumococcal vaccine (Prevnar 13)
on 12/1/2021 and no additional pneumococcal vaccines since then.
On 3/11/25 at 1:04 PM, V3 (Infection Preventionist) said that the nurses ask residents upon admission
about their immunization history and if they are due for a pneumococcal vaccine, she speaks with them,
gets a consent and gives the appropriate vaccine. V3 said that she uses the table from the CDC (Centers
for Disease Control and Prevention) to determine what pneumococcal vaccine is needed. V3 said that after
reviewing the table, R52 should have received the Prevnar 20 vaccine a year after her Prevnar 13 vaccine.
The CDC Pneumococcal Vaccine Timing for Adults table dated 10/2024 shows that adults [AGE] years of
age or older that have had the Prevnar 13 vaccine only should receive the Prevnar 20 or Prevnar 21
vaccine one year later.
The facility's Pneumococcal Vaccination Policy dated 6/20/21 shows, Administration of pneumococcal
vaccines or revaccinations will be made in accordance with current Centers for Disease Control and
Prevention (CDC) recommendations at the time of the vaccination.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145612
If continuation sheet
Page 9 of 9
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17 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0291GeneralS&S Epotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0351GeneralS&S Epotential for harm
Install an approved automatic sprinkler system.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
- 0223GeneralS&S Epotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0531GeneralS&S Fpotential for harm
Have elevators that firefighters can control in the event of a fire.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F919 - Resident Call System
Meet requirements for the use of electrical equipment.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
FAQ · About this visit
Common questions about this visit
What happened during the March 12, 2025 survey of PEARL OF CRYSTAL LAKE, THE?
This was a inspection survey of PEARL OF CRYSTAL LAKE, THE on March 12, 2025. The surveyor cited 17 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PEARL OF CRYSTAL LAKE, THE on March 12, 2025?
Yes, 17 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Install emergency lighting that can last at least 1 1/2 hours."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.