Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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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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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 | — | 3 | 0 |
| Alden Terrace Of Mchenry Rehab | 4.9 mi | — | 5 | 0 |
| Crystal Pines Rehab & Hcc | 5 mi | — | 4 | 0 |
| Alta Rehab At Wauconda | 7 mi | — | 2 | 0 |
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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.