Pearl of Crystal Lake, The

In the surveyor’s words

From the most serious findings on record at Pearl of Crystal Lake, The, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 4, 2026

  Based on observation, interview and record review, the facility failed to unload the clean dishes from the dishwasher in a sanitary manner and failed to document cooling temperatures. This applies to all the residents in the facility.The findings include:The CMS (Center for Medicare and Medicaid Services) 671 dated 6/2/26 shows there were 77 residents in the facility.On 6/2/26 at 9:24 AM, V4 [NAME] was observed wearing gloves and loading the dishwasher with the dirty dishes. V4 then rinsed her gloves off using the sink sprayer, then wiped them against her cloth apron and began removing the clean dishes from the dishwasher. […]

• No harm, potential for more than minimal, widespreadF812Aug 31, 2023

  Based on observation, interview, and record review the facility failed to store and thaw foods in a manner that prevents cross-contamination and food borne illness. This has the potential to affect all residents in the facility. The findings include: The completed Facility Data Sheet dated 8/31/23, shows a census of 63 residents. 1. On 8/31/23 at 8:48 AM, black portion cups filled with mandarin oranges were in the refrigerator by the ice machine without a date and label. On 8/31/23 at 8:50 AM, two bowls of an unknown soup were in the refrigerator by the ovens without a date and label. […]

• No harm, potential for more than minimal, widespreadF812Jan 21, 2021

  Based on observation, interview, and record review the facility failed to ensure food was properly labeled and stored based upon professional standards for food service safety. This has the potential to affect all residents in the building. The findings include: The facility's census and condition report dated 1/19/21 showed 32 residents residing in the facility. On 1/19/21 at 10:30AM, observations during the initial tour of the dry storage area showed 4 containers of unlabeled items on a shelf in containers. V4 (Dietary Manager) stated, those are dry food items like flour and rice, everyone knows what they are so we don't have to label them. On 1/19/21 at 10:33AM, observations of the refrigerator in the kitchen showed several containers of liquid with no received or use by date. […]

• No harm, potential for more than minimal, patternF755Jun 4, 2026

  Based on observation, interview, and record review, the facility failed to administer medications as ordered by a physician for 3 residents (R65, R100, R101), failed to safely administer medications to 1 resident (R38), failed to ensure medications were not left at the bedside for 2 residents (R41, R45). These failures apply to 6 of 6 residents reviewed for pharmacy services in the sample of 44. The findings include:1. R38's electronic face sheet dated 6/4/26 showed R38 has diagnoses including but not limited to end stage renal disease, type 2 diabetes, chronic obstructive pulmonary disease (COPD), and depression. R38's facility assessment dated [DATE] showed R38 has no cognitive impairment. […]

• No harm, potential for more than minimal, patternF803Mar 12, 2025

  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. […]