Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pearl Of Crystal Lake, The during CMS and state inspections, most recent first.
Unsafe dish handling and missing cooling temperature documentation: A Dietary Manager was observed handling clean dishes after touching dirty dishes without washing hands or changing gloves, and a pan of cooked chicken was found in the refrigerator with no routine cooling documentation. The DM said the chicken was cooled in ice, that the facility usually does not use cooling logs or stickers, and later produced a cooling log after the fact; production logs for the prior 3 months did not include cooling temps.
Medication administration failures occurred when ordered meds were given hours late or not given at all for several residents, including one resident whose evening carvedilol dose was missed and others whose morning meds were administered far outside the ordered window. Staff also left meds and inhalers at the bedside for two residents without orders, self-administration assessments, or care plans, and one RN left a resident’s morning meds in the room after the resident said she would take them later.
Failure to notify the provider of elevated blood sugars. A resident with type 2 DM had an order to notify the MD if 2 consecutive blood sugars were greater than 349, but nursing documented three consecutive elevated readings and no communication with the provider was found in the EHR. The DON stated staff should follow orders as written and notify the provider when required.
A resident was sent to the hospital after becoming unresponsive at dialysis, but the chart did not document the transfer, where she went, or the reason for the transfer. The record only showed an episode of emesis and later skilled charting with VS, mental status, and functional status. The DON confirmed the resident was not at baseline and had a change in condition, and stated an SBAR is normally documented, but none was found.
Failure to Provide Nail Care for a Dependent Resident: A resident with paralysis, dementia, and severe cognitive impairment required substantial/maximal assistance with personal hygiene and bathing, yet fingernails on both hands were observed dirty and overgrown on consecutive observations. The resident said the nails were long and needed trimming, and a CNA confirmed the resident needed help with most care and that the nails did not appear to have been trimmed in a while. The DON stated nail care should be offered on shower days and is important for hygiene and cross-contamination.
Pressure ulcer prevention measures were not in place for two residents at risk for skin breakdown. One resident with a right heel DTI and sacral PU was observed in bed with heel boots sitting in a chair nearby and heels flat on the mattress, despite a care plan calling for heel offloading. Another resident with dementia, PVD, and fragile skin was observed with knees rubbing together and heels rubbing on the mattress without pillows, wedges, or other pressure relief devices in place, even though the care plan included heel offloading and leg separation.
Fall Prevention Not Maintained for Resident on Oxygen: A resident at high risk for falls was observed with oxygen tubing draped across the bed and coiled on the floor in her room while she sat in a wheelchair. The resident reported 17 falls in 6 months, said she was not supposed to get up alone, and stated she had fallen at the facility when trying to step over the tubing and it caught around her ankles. Records showed multiple fall-related diagnoses, no cognitive impairment, and a care plan identifying her as high risk for falls with an actual fall documented; the DON stated the tubing should not have been laying on the floor.
A resident receiving O2 and scheduled nebulizer treatments had his nebulizer machine on the nightstand with the face mask uncovered and laying in an open drawer with other items. The resident had recent pneumonia, PE, CHF, pleural effusion, and Guillain-Barre syndrome, and the facility’s RN stated the mask should be stored in a bag and covered for infection control; the facility policy stated to store it in a plastic bag.
Failure to provide pain medication before therapy for a resident with a recent knee replacement. The resident said she asked for her pain pill before PT, but it was not given until after therapy had already occurred. The RN stated she gave hydrocodone/acetaminophen later for severe pain, and the Therapy Director noted that pain meds can help residents with recent joint replacements tolerate therapy.
Significant delay in insulin administration. A resident with CHF, HTN, type 2 DM, and cirrhosis had an order for Humalog insulin with meals, but the noon dose was missed and later given nearly 2 hours after the scheduled time. The DON acknowledged the resident had not received the insulin at lunch, and the MAR showed the dose was administered at 1:58 PM instead of within the ordered time window.
Pureed Food Prepared Without Following Recipe: The facility failed to prepare puree foods according to the recipe for two residents ordered pureed diets. An aide pureed Asian fried rice with plain water instead of broth, and the mixture had no flavor until salt was added. The DM and dietician stated the recipe called for broth to be used to achieve the proper consistency and palatability, and the residents involved had diagnoses including dementia, dysphagia, and Alzheimer's disease with physician orders for pureed foods.
A resident with an EBP sign posted for a surgical wound site was observed receiving high-contact care without the required PPE. A CNA touched and adjusted the mattress and linens without gloves or a gown, and later an RN entered with gloves but no gown and continued checking the mattress and resident positioning. Staff gave inconsistent explanations of when EBP applies, while the DON and Administrator stated the posted EBP sign should be followed with gown and gloves during high-contact care.
The facility did not adhere to the prescribed menu for residents on a pureed diet, resulting in incorrect portion sizes and missing meal components. The dietary manager used the wrong scoop size and omitted certain items due to misreading the menu and being preoccupied with training duties. The dietitian confirmed the importance of following the menu and portion sizes to ensure residents receive a balanced diet.
A resident with morbid obesity and a fractured leg was not provided with an appropriate wheelchair, leading to discomfort and safety concerns. The resident was observed being transferred into a standard wheelchair that was too small, causing improper positioning and discomfort. The facility staff acknowledged the need for a bariatric wheelchair to accommodate the resident's needs.
The facility failed to obtain treatment orders for a resident's non-pressure wound and did not consistently monitor daily weights for another resident with CHF. The wound care nurse was not informed of the skin tears, and the resident's records lacked a treatment plan. Additionally, the facility did not record weights on several days for a resident with CHF, despite physician orders to monitor for weight changes.
The facility failed to implement necessary interventions for residents with pressure injuries. A resident with a stage 4 sacral injury was found on a regular mattress instead of the prescribed low air loss mattress. Another resident with a foot injury was observed without heel protector boots, and a third resident with multiple injuries was found without heel protectors or offloading. These oversights occurred despite care plans and the facility's policy requiring such interventions.
A facility failed to implement a care plan intervention for a resident at risk for malnutrition. The resident, with severe protein-calorie malnutrition and other medical conditions, was not weighed according to the physician's order, resulting in a 17-day gap between weigh-ins. The dietician noted the lack of timely notification from nursing staff about weight changes, and the resident confirmed being weighed only once after admission. The facility's policy requires regular weight monitoring and documentation, which was not adhered to.
A facility failed to ensure staff wore the required PPE for a resident on enhanced barrier precautions due to a wound. The resident's care plan and facility policy required gloves and gowns during high contact activities like transferring. However, during a session with an OT and PT, only gloves were worn, not gowns, despite the Infection Control Nurse's acknowledgment of the requirement.
A facility failed to administer a pneumococcal vaccine to a resident as per CDC guidelines. The resident, with multiple health conditions, consented to receive the vaccine, but her immunization report showed she only received the Prevnar 13 vaccine in 2021 and no additional vaccines since. The Infection Preventionist confirmed that the resident should have received the Prevnar 20 vaccine a year later, as per CDC recommendations, which was not done.
A resident's $75 went missing shortly after admission, and the facility's investigation, including interviews and video surveillance, failed to determine the money's whereabouts. The resident had no cognitive impairment, and inconsistencies were found in the facility's documentation regarding the handling of the money. Despite reporting the incident to public health and the police, the facility could not provide evidence of staff involvement, and no specific theft policy was available.
The facility failed to ensure staff wore the required PPE when entering COVID-19 isolation rooms. CNAs entered rooms without necessary eye protection and wore surgical masks under N95 masks, contrary to facility policy. Additionally, a CNA reused a face shield and N95 mask across different resident rooms. The facility's policy mandates specific PPE for residents suspected or confirmed to have COVID-19, which was not followed despite staff training.
A facility failed to document the administration of an as-needed acetaminophen dose in a resident's MAR. An RN provided the medication for pain but did not record it, as confirmed by the DON. The MAR showed no record of the medication, contrary to the facility's policy requiring documentation.
A resident on hospice care and bed-bound fell out of bed and sustained injuries due to improper repositioning by a CNA. The resident, who required a two-person assist with a mechanical lift, was being repositioned by a single CNA who was unaware of the specific requirements. The resident's large size and lack of side rails on the bed contributed to the fall.
Unsafe dish handling and missing cooling temperature documentation
Penalty
Summary
The facility failed to unload clean dishes from the dishwasher in a sanitary manner. On 6/2/26 at 9:24 AM, V4 was observed wearing gloves while loading dirty dishes into the dishwasher, then rinsing the gloves with the sink sprayer, wiping them on a cloth apron, and removing clean dishes from the dishwasher without removing the gloves or washing hands first. V4 was observed doing the same thing again at 9:28 AM. The facility policy for hand washing states food service employees will practice safe food handling and thoroughly wash their hands with soap and water after touching unsanitary items such as dirty dishes. The facility also failed to document cooling temperatures. On 6/2/26 at 9:59 AM, a pan of cooked cut-up chicken was observed in the refrigerator with a prepared date of 6/1/26. V3, the Dietary Manager, said he cooked the chicken the day before and cooled it by resting it in a pan of ice, and said he checked the temperatures as it cooled. He stated the facility does not use cooling logs or cooling stickers because most foods are cooked the day they are served. Later, V3 provided a June 2026 cooling log for the chicken, but on 6/4/26 he provided production logs for the last 3 months that did not include any cooling temperatures. V3 said he was the staff member who prepared the chicken on 6/1/26 and made the cooling log for the surveyor after the fact.
Medication Administration and Bedside Storage Failures
Penalty
Summary
The facility failed to provide pharmaceutical services to meet residents’ needs by not administering medications as ordered for three residents, by leaving medications at the bedside for two residents without orders or self-administration assessments, and by safely administering medications for one resident. The report states these failures applied to 6 of 6 residents reviewed for pharmacy services in the sample of 44. For one resident with end stage renal disease, type 2 diabetes, COPD, and depression, morning medications including duloxetine, loratadine, sevelamer, and Lyrica were left in the room on the nightstand after the resident said she was nauseous and would take them later. The resident had no assessment or care plan for self-administration, and the DON stated the resident should have been supervised while taking medications because no self-administration assessment existed. An agency RN stated she did not have time to give the medications one by one and left them because the resident said she would take them. For another resident with dementia, Alzheimer’s disease, and severe cognitive impairment, ordered medications including Depo-Provera, aspirin, phosphatidylserine, tizanidine, guaifenesin, Colace, and ferrous sulfate were administered more than 6 hours after the scheduled time. For a resident with chronic leukemia, acute kidney failure, pneumonia, COPD, and emphysema, multiple morning medications including allopurinol, escitalopram, Lasix, metoprolol, potassium chloride, aspirin, omeprazole, folic acid, simvastatin, thiamine, diphenoxylate-atropine, and gabapentin were given more than 5 hours late. For a newly admitted resident with hypertension, anxiety, and depression, the 5:00 PM carvedilol dose was not given, and the resident reported concern after her blood pressure was elevated the next morning. The report also describes two residents whose medications were left at the bedside without authorization for self-administration. One resident had an albuterol inhaler on the tray table, and another resident had Preservision and a Trelegy Ellipta inhaler at the bedside. The facility’s records showed no self-administration assessment or care plan for these residents, and staff confirmed there were no orders to leave the medications at the bedside or to allow self-administration.
Failure to Notify Provider of Elevated Blood Sugars
Penalty
Summary
The facility failed to notify a resident's provider when the resident's blood sugar was outside the specified parameters. R7 was admitted with a diagnosis of type 2 diabetes, and the order listing showed an instruction to notify the MD if 2 consecutive blood sugars were greater than 349. On 3/23/26, R7 had three elevated blood glucose readings documented at 6:01 AM of 401, at 8:24 AM of 390, and at 11:49 AM of 368. The electronic health record contained no documented communication between nursing staff and the provider regarding these values. The DON stated staff should follow orders as written and notify providers when ordered, and could not find documentation that the provider had been notified of the three consecutive blood sugars above 349.
Failure to Document Hospital Transfer and Basis for Transfer
Penalty
Summary
The facility failed to ensure that a resident’s transfer to the hospital was documented and that the basis for the transfer was recorded for one resident reviewed for transfers. On 6/4/26, the resident was not in her room and her belongings, including her wheelchair, were still there. A registered nurse stated the resident had gone to the hospital after becoming unresponsive at dialysis the day before. Record review showed an episode of emesis at 1:58 AM on 6/3/26 and a skilled charting note at 4:06 PM documenting vital signs, mental status as alert and oriented x 3, and functional status, but there was no note explaining what happened, why the resident was sent out of the facility, or where she went. The DON stated the resident was at dialysis, was not responding like normal, was not at baseline, had a change in condition, and was sent to the hospital. The DON also stated an e-interact SBAR is normally documented, but the chart contained no note showing what happened, where the resident went, why she was sent out, or follow-up information. The facility’s policy stated that when a resident becomes unstable or deteriorates, emergency procedures may apply and all attempts to contact providers, the resident’s status, and nursing actions must be documented.
Failure to Provide Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide nail care for a resident who was unable to perform activities of daily living independently. The resident’s admission record showed diagnoses including paralysis affecting the right side, dementia, and cognitive communication deficit. The 5/8/26 Significant Change MDS showed severe cognitive impairment with a BIMS score of 5 out of 15, substantial/maximal assistance needed for personal hygiene and showering/bathing, and an impairment to one side of the upper body. On 6/2/26, the resident was observed asleep in bed with the right hand stiff and contracted, and the fingernails on both hands were dirty and about 0.25 inches past the cuticle bed. On 6/3/26, the fingernails were observed in the same condition, and the resident stated the nails were long, needed trimming, and that he liked having them trimmed. A CNA stated the resident needed assistance with most care, could not move the right hand, and that nail care was done on shower day, but the nails did not appear to have been trimmed in a while. The DON stated nail care should be offered on shower days and that it is important for hygiene and cross-contamination. The resident’s nails were trimmed by 6/4/26.
Pressure ulcer prevention devices not in place for two residents
Penalty
Summary
The facility failed to ensure pressure ulcer prevention measures were in place for 2 residents who were identified as being at risk for pressure injuries and already had existing skin breakdown. One resident had diagnoses including a displaced right femur fracture, osteoporosis, hypertension, a pressure-induced deep tissue injury of the right heel, and an unstageable sacral pressure ulcer. The resident’s assessment showed no cognitive impairment but documented risk for pressure ulcers, and the care plan included sacral and heel pressure ulcers related to impaired mobility, recent surgery, incontinence, and limited repositioning, with heel offloading listed as an intervention. For that resident, the wound assessment described a right heel deep tissue injury that had opened before the wound nurse practitioner’s first visit, and the resident was on a low air loss mattress and reminded to use heel protector boots while in bed. During observation, the heel boots were found sitting in a chair next to the bed, and the resident was observed lying in bed with heels flat on the mattress. The resident stated the boots were used to prevent sores on the back of the foot and that they were not needed all the time. A CNA stated the resident had pressure ulcer prevention measures including an air mattress, heel boots, and side-to-side turning, and the DON stated the interventions were a low air loss mattress and heel protectors while in bed. The second resident had diagnoses including frontotemporal neurocognitive disorder, dementia with behaviors, vascular dementia, peripheral vascular disease, anxiety disorder, and adjustment disorder. The resident’s assessment showed severe cognitive impairment and risk for pressure ulcers, and the care plan identified fragile skin, incontinence, restless legs, impaired mobility, and prior skin discolorations, with heel offloading using pillows when in bed. During observation, the resident was lying in bed with the head of bed elevated, with no pillow between the legs, knees rubbing together, and feet and heels rubbing back and forth on the mattress without a pressure relief device in place. A wedge cushion and knee separation cushion were on the bedside table across the room. Later, the resident was again observed in bed with no pressure prevention device on the feet or between the knees, while a CNA stated the resident’s prevention measures included an air mattress, repositioning, pillows to elevate the heels, and a pillow between the legs, and the DON stated the resident’s measures were a low air loss mattress and lamb’s wool.
Fall Prevention Not Maintained for Resident on Oxygen
Penalty
Summary
The facility failed to ensure fall preventative measures were in place for a resident at high risk for falls. On 6/2/26, the resident was observed sitting in a wheelchair in her room with oxygen via nasal cannula, while a small portable oxygen tank sat on the dresser across the room. The oxygen tubing extended from the tank, draped across the bed, and was coiled on the floor in front of the resident. The resident stated she had been in and out of the facility for rehabilitation services, had 17 falls in 6 months, was not supposed to get up on her own, and had gotten up while waiting for help to go to the bathroom. She also stated she had fallen at the facility when trying to step over the oxygen tubing and it became caught around her ankles. Record review showed the resident had diagnoses including a prior fall, COPD, type 2 DM, morbid obesity, long-term anticoagulant use, abnormal gait and mobility, lack of coordination, anxiety disorder, rheumatoid arthritis, a left artificial knee joint, and dependence on supplemental oxygen. Her MDS showed no cognitive impairment. An SBAR note documented that she was found sitting on the floor at the toilet after stating she was trying to untangle the oxygen tubing around her feet and landed on the floor. Her care plan identified her as high risk for falls related to frequent falls and weakness/deconditioning, and it documented an actual fall on 5/14/26. The DON stated the resident was at high risk for falling and the oxygen tubing should be out of the way and not laying on the floor.
Nebulizer Mask Left Uncovered in Resident Room
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained for R41 when the facility failed to store his nebulizer in a manner to prevent cross contamination. During observation on 6/3/26 at 10:27 AM, R41 was sitting in a wheelchair in his room with oxygen via nasal cannula. His nebulizer machine was on the nightstand, and the drawer was open with the nebulizer face mask uncovered and laying in the drawer with other items. R41 also had an albuterol inhaler and incentive spirometer on his tray table. R41 stated he would be okay if his breathing was better and reported he had been in the hospital for 26 days because of pneumonia and a blood clot, including time in the intensive care unit. He also stated he was diagnosed with Guillain Barre in December 2025. The administrator/RN stated the nebulizer mask should be stored in a bag and covered for infection control. R41’s diagnoses included pneumonia, pulmonary embolism, acute on chronic systolic CHF, pleural effusion, paroxysmal atrial fibrillation, Guillain-Barre syndrome, type 2 DM, dyspnea, anxiety disorder, dependence on supplemental oxygen, burn of unspecified degree of abdominal wall, sacral pressure ulcer, DVT, major depressive disorder, hypotension, hyperlipidemia, atrial fibrillation, hypokalemia, depression, polyneuropathy, restless leg syndrome, and cardiomegaly. Physician orders included Ipratropium-Albuterol inhalation solution twice daily for shortness of breath/wheezing, and the care plan addressed shortness of breath and oxygen therapy. The facility’s nebulizer therapy policy stated to store in a plastic bag.
Failure to Provide Pain Medication Before Therapy
Penalty
Summary
The facility failed to provide pain medication for a resident prior to therapy. R101 was admitted on 6/1/26 with diagnoses including joint replacement surgery, right artificial knee joint, and type two diabetes. On 6/2/26, R101 told surveyors that she asked for her pain pill before therapy, which was scheduled for 10:00 AM, but it did not happen. She stated that therapy hurt that morning and that the pain pill would have helped. The record showed R101 received hydrocodone/acetaminophen at 11:07 AM on 6/2/26 for a pain rating of 8 out of 10, after she said therapy had already been done. The RN stated she gave the medication after R101 reported bad pain and said she did not know when therapy would occur or that the resident needed pain medication before therapy. The Therapy Director stated that residents with recent joint replacements can have pain with therapy and that pain medication can help them endure therapy and do more during therapy. The facility's pain management policy stated it would provide adequate pain assessment and management so residents attain or maintain the highest practicable physical, mental, and psychosocial well-being.
Significant delay in insulin administration
Penalty
Summary
The facility failed to ensure that a resident was free from a significant medication error when R66 did not receive scheduled Humalog insulin at the ordered noon administration time. R66’s record showed diagnoses including congestive heart failure, hypertension, type 2 diabetes, and cirrhosis of the liver, and the physician’s order directed Humalog 100 unit/mL to be injected per sliding scale subcutaneously with meals for diabetes mellitus. On 6/3/26 at 1:47 PM, the DON stated that it did not look like R66 had received her insulin at noon with lunch and that the facility was checking blood sugars and vitals on residents who had missed or were late on medications. The MAR showed R66 received the Humalog insulin at 1:58 PM, which was 1 hour and 58 minutes past the scheduled administration time. The facility policy stated that if a medication is given at a different time than scheduled, the MAR should be updated to reflect the administration time, and that scheduled medications will be given within an hour window before and after the scheduled time as preferred by the resident.
Pureed Food Prepared Without Following Recipe
Penalty
Summary
The facility failed to ensure puree foods were prepared according to the recipe to maintain palatability for two residents who were ordered to receive pureed diets. On 6/2/26, V4 was preparing Asian fried rice for lunch and pureeing it with plain hot water to achieve the correct consistency. After V4 and the surveyor tasted the mixture and found it had no flavor, V3, the Dietary Manager, instructed V4 to add salt. V4 stated the rice had been cooked in chicken broth, but she used water to puree it. V3 later stated V4 should have used chicken broth as the liquid to puree the rice and said he had started boiling water to make broth, but V4 used the water before he could finish. The dietician stated that if the recipe calls for broth to be added while pureeing the rice, staff are to follow that instruction, and that chicken broth would make the rice more palatable for residents. The recipe for Asian Fried Rice directed staff to process the rice until a smooth pudding-like consistency was achieved and to add juice, milk, or broth, whichever was most appropriate, a little at a time to reach the desired consistency. The facility records showed R9 had diagnoses including dementia and dysphagia and had a physician order for pureed foods, and R65 had a diagnosis of Alzheimer's Disease and a physician order for pureed foods. The facility policy for standardized recipes stated that recipes are to be followed throughout production.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were followed for one resident with an EBP sign posted on the doorway. On 6/2/26 at 10:28 AM, the resident was observed in bed with an air mattress in place and stated that his bottom hurt because it felt like the bed was inflated enough; another resident stated it felt like his bottom was touching the metal of the bed. A CNA entered the room without gloves or a gown, removed the blankets, and touched and pressed all over the mattress to check the inflation and moved the linen around to look at the mattress. Later that morning, a restorative nurse entered the room, put on gloves but did not wear a gown, and pushed on the mattress and placed her hands and forearms under the resident to check whether the mattress was flat under him. When asked about the EBP sign, the CNA stated the resident had surgery to remove his feeding tube and the site had opened and been draining, which was why he was on EBP. The restorative nurse stated EBP was for residents with a stage 3 or higher open wound and that was when EBP had to be followed. Later, the CNA stated she should have had gloves on when touching the resident and his linen because it was close contact. The DON and the Administrator agreed that staff should follow the EBP sign and that gown and gloves should be worn for high-contact care. The resident’s physician orders and care plan showed EBP precautions for a surgical wound site, and the facility’s policy stated EBP requires targeted gown and glove use during high-contact resident care activities.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to ensure that the menu was followed to meet the nutritional needs of residents on a pureed diet. Specifically, four residents on a pureed diet were not provided with the correct portions and items as outlined in the facility's menu extension sheet. On March 10, 2025, the pureed sloppy joe was prepared without the bread serving, and the residents were served a smaller portion than specified. Additionally, the residents did not receive the pureed mixed fruit that was part of their meal plan. On the following day, March 11, 2025, the same residents did not receive the pureed strawberry jello cake as indicated in the menu extension sheet. The dietary manager, V15, admitted to using the wrong scoop size for the pureed sloppy joe and failing to serve the bread serving and pureed mixed fruit due to being busy with training. Furthermore, V15 misread the menu extension sheet, resulting in the omission of the pureed strawberry jello cake. The dietitian, V12, confirmed that the menus and portion sizes should be strictly followed to ensure a balanced diet for the residents. The facility's portion control chart specifies the correct scoop sizes, which were not adhered to in this instance.
Inadequate Wheelchair Accommodation for Morbidly Obese Resident
Penalty
Summary
The facility failed to provide an appropriate wheelchair for a resident who is morbidly obese, leading to discomfort and potential safety risks. The resident, identified as R128, was admitted with a diagnosis of a fractured left lower leg, morbid obesity, and congestive heart failure. During an observation, two CNAs attempted to transfer R128 into a standard wheelchair using a mechanical lift. However, the wheelchair was too small, and the resident's midsection was wider than the chair, causing discomfort and improper positioning. Despite efforts by the CNAs to adjust the resident, R128 expressed discomfort and was unable to fit properly in the wheelchair. The situation was escalated to the resident's nurse, who confirmed that the wheelchair was too small and recommended returning the resident to bed for safety. The restorative nurse acknowledged that a bariatric wheelchair was necessary for R128, as the current chair was a regular size. The therapy director confirmed that a size 26 bariatric wheelchair was needed to ensure the resident's comfort and safety. The facility's policy on accommodating residents' needs was not adhered to, as the resident's individual needs were not met, leading to this deficiency.
Failure to Obtain Treatment Orders and Monitor Weights
Penalty
Summary
The facility failed to obtain treatment orders for a non-pressure wound for a resident who had sustained skin tears on her left forearm following a fall. The resident was observed with different dressings on consecutive days, neither of which had a documented treatment order. The Wound Care Nurse was not informed of the wound, and the facility's records did not reflect the presence of the skin tears until several days after the incident. This lack of communication and documentation resulted in the absence of a physician-directed treatment plan for the resident's wounds, contrary to the facility's policy. Additionally, the facility did not adhere to physician orders for daily weight monitoring for a resident with congestive heart failure (CHF). The resident's records showed multiple days where weights were not recorded, despite orders to monitor for weight changes that could indicate fluid overload. The Director of Nursing acknowledged the importance of daily weights for residents with CHF to prevent complications, yet the facility failed to consistently implement this critical monitoring.
Failure to Implement Pressure Injury Interventions
Penalty
Summary
The facility failed to implement necessary interventions for residents with pressure injuries, as observed in three cases. Resident R127, who was admitted with a stage 4 sacral pressure injury, was found lying on a regular mattress instead of the prescribed low air loss mattress, which was crucial for her condition. Despite the care plan indicating the need for pressure-relieving surfaces, R127 was left on wet sheets, exacerbating her condition. The oversight occurred after R127 was readmitted from the hospital and moved to a different room without the appropriate mattress. Similarly, Resident R62, who had a stage 4 pressure injury on his right foot, was observed without the required heel protector boots while in bed, contrary to his care plan. The boots were meant to offload pressure from his heels, but they were found across the room instead of being worn. Resident R44, with multiple pressure injuries, including a stage 4 injury to her sacrum and unstageable injury to her right heel, was also found without heel protectors or offloading, as required by her care plan. The facility's failure to adhere to its Wound Prevention and Healing policy, which mandates interventions to prevent pressure injuries, was evident in these cases.
Failure to Implement Weight Monitoring for Resident at Risk for Malnutrition
Penalty
Summary
The facility failed to implement a care plan intervention for a resident at risk for malnutrition. The resident, a female with a history of gastric bypass surgery and multiple medical conditions including severe protein-calorie malnutrition, was admitted with a care plan that required her weight to be monitored regularly. However, the facility did not adhere to the physician's order for weight monitoring, which specified weighing the resident on admission day, the following day, and weekly for four weeks. Instead, the resident was weighed only once on 2/14/25 and not again until 3/3/25, a gap of 17 days. The dietician, V12, acknowledged awareness of the resident's weight loss upon running a weight report on 3/4/25 and noted that the nursing staff did not always notify her of weight changes promptly. The resident confirmed being weighed only once after admission and expressed no refusal to be weighed using a mechanical lift. The facility's Weight Management policy, last reviewed on 8/20/24, mandates that weights be documented in the resident's electronic medical record, which was not followed in this case.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore the required personal protective equipment (PPE) for a resident on enhanced barrier precautions. The resident, identified as R178, had a wound and was ordered to be on enhanced barrier precautions, which included the use of gloves and gowns during high contact activities such as transferring. On March 10, 2025, the Infection Control Nurse placed a sign on the resident's door indicating the need for enhanced barrier precautions. However, during a session where the Occupational Therapist and Physical Therapist assisted the resident to stand, walk, and sit, they only wore gloves and did not wear gowns as required. The facility's policy, revised on March 28, 2024, clearly stated that transferring is a high contact activity necessitating both gloves and gowns. The failure to adhere to these precautions was observed and confirmed by the Infection Control Nurse, who acknowledged the requirement for both gloves and gowns during such activities.
Failure to Administer Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to ensure that a resident received a pneumococcal vaccine as per CDC recommendations. The resident, who is [AGE] years old, was admitted with multiple diagnoses including end stage renal disease, chronic obstructive pulmonary disease, and congestive heart failure. She had given consent to receive the pneumococcal vaccine on 10/14/24. However, her immunization report showed that she had only received the Prevnar 13 vaccine on 12/1/2021 and no additional pneumococcal vaccines since then. The Infection Preventionist (V3) stated that nurses inquire about residents' immunization history upon admission and administer vaccines as needed. V3 acknowledged that according to the CDC's pneumococcal vaccine timing table, the resident should have received the Prevnar 20 vaccine a year after her Prevnar 13 vaccine. The facility's policy also indicated that pneumococcal vaccinations should be administered in accordance with CDC recommendations, which was not followed in this case.
Failure to Prevent Theft of Resident's Money
Penalty
Summary
The facility failed to prevent the theft of a resident's personal money, resulting in a deficiency related to the misappropriation of property. A resident, who was admitted with $75 documented on her inventory sheet, reported the money missing a few days after admission. Despite a thorough search of the resident's belongings and room, as well as interviews with staff, residents, and family, the facility was unable to determine the whereabouts of the money or when it went missing. Video surveillance was reviewed, but it did not provide any evidence of staff or the resident's son taking the money. The resident involved had a medical history that included a history of falls, weakness, cervical disk degeneration, age-related osteoporosis, and bilateral hearing loss. She was assessed to have no cognitive impairment with a perfect score on the Brief Interview for Mental Status (BIMS). The facility's records showed inconsistencies in documenting the handling of the resident's money, with initial notes indicating the son would take the money home, but later entries contradicting this. The facility's investigation did not yield any findings, and the incident was reported to public health and the police. The facility's abuse prevention program policy was reviewed, which emphasized the protection of residents from misappropriation of property. However, no specific theft policy was provided during the investigation. The facility's administrator and social services director believed the resident's son took the money, but there was no evidence to support this claim.
Improper PPE Use in COVID-19 Isolation Rooms
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) by staff when entering COVID-19 isolation rooms. Several instances were observed where staff did not adhere to the required PPE protocols. A Certified Nursing Assistant (CNA) entered the rooms of residents on droplet and contact isolation without wearing the necessary eye protection and wore a surgical mask under an N95 mask, which is against the facility's policy. Another CNA entered a resident's room without eye protection, despite signs indicating it was required. Additionally, a CNA failed to properly dispose of a face shield after use and reused an N95 mask when entering another resident's room, which was not on isolation. The facility's policy, dated October 20, 2021, requires staff to wear an N95 respirator, eye protection, gown, and gloves for residents suspected or confirmed to have COVID-19. Despite being in-serviced on the correct PPE usage, staff did not comply with these guidelines. The Director of Nursing (DON) and the Assistant Director of Nursing/Infection Control confirmed that staff should not wear surgical masks under N95 masks as it may compromise the seal, and PPE should be disposed of after each use before entering another resident's room.
Failure to Document As-Needed Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of an as-needed medication in a resident's Medication Administration Record (MAR). During an interview, a Registered Nurse (RN) admitted to administering acetaminophen 650 milligrams to a resident who reported experiencing pain at a level of 6 out of 10. However, the RN forgot to document this administration in the MAR. The Director of Nursing (DON) confirmed that it is the nurse's responsibility to document any medication provided to residents in their MAR. A review of the resident's MAR for July 2024 showed no record of the as-needed acetaminophen being administered, despite the facility's Medication Administration policy requiring documentation as each medication is prepared.
Failure to Safely Assist Resident with Repositioning
Penalty
Summary
The facility failed to ensure staff safely assisted a resident with repositioning in bed, leading to a fall and subsequent injuries. The resident, who was on hospice care and bed-bound, had two scabs from lacerations on his forehead and a 10-inch laceration on the top of his head with seven staples. The incident occurred when a CNA was performing incontinence care, and the resident rolled himself over too far, falling out of bed. The CNA was alone and unable to prevent the fall, despite the resident's care plan indicating that he required a two-person assist with a mechanical lift for transfers and repositioning. The resident's medical records and interviews with staff and family members confirmed that the resident was a large man, approximately 6 feet 6 inches tall, and weighed 231.4 pounds. He was on an air mattress without side rails or anything to hold onto, making it difficult to reposition him safely. The CNA involved in the incident admitted that she was unaware of the specific repositioning requirements for the resident. The facility's fall prevention and management policy emphasized the importance of ensuring a safe environment and proper positioning, which was not adhered to in this case.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 473 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Crystal Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair Oaks Health Care Center | 3.1 mi | ★★★★★ | 2 | 0 |
| Ignite Medical Mchenry | 3.6 mi | ★★★★★ | 16 | 0 |
| Alden Terrace Of Mchenry Rehab | 4.9 mi | ★★★★★ | 17 | 0 |
| Crystal Pines Rehab & Hcc | 5 mi | ★★★★★ | 6 | 0 |
| Alta Rehab At Wauconda | 7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.