Health inspection·January 12, 2023

F 0658 is available or they need to call the pharmacy to have them provide the facility with the ordered medication. Level of Harm - Minimal harm or potential for actual harm On January 12, 2023, V10 (Regional Nurse Consultant) provided a Controlled Substance Proof of Use Sheet to show on December 30, 2022, R214 was prescribed Tramadol 50 mg (milligrams) every 6 hours as needed for pain. V10 could not say why the nurse had not entered the order into the computer. V10 also stated when signing the MAR if there was no dosage/amount (Milligrams) written then the nurses should have verified the order in the computer or with the physician. The pharmacy had sent the medication card, and this is where the nurses were getting R214's Tramadol dosage. R214's medication card was empty, no one called the physician or the pharmacy to reorder the medication. On January 10, 2023, at 6:00 AM there was no Tramadol in the controlled substance drawer for R214, so the nurse borrowed from a discharged resident's medication card, this is not a good practice. Residents Affected - Few 2. R56's EMR showed R56's diagnoses included spondylolysis lumbar region, spinal stenosis lumbar region, malignant neoplasm of unspecified part or unspecified bronchus or lung, malignant neoplasm of peritoneum. R56's MDS dated [DATE], showed R56 was cognitively intact. R56 required extensive assistance for bed mobility, transfers, dressing, and personal hygiene. R56 required one staff extensive assistance for toilet use. R56's POS dated December 15, 2022, showed Dexamethasone 4 mg, Give 2 tablets by mouth one time a day for prophylaxis, Take 8 (mg) on days 2 and 3 of treatment (chemo). R56's MAR for December 18 to December 29, 2022, shows R56 was given 8 mg of Dexamethasone daily. On January 11, 2023, at 2:10 PM, V12 (Physician) stated R56's Dexamethasone (steroid) was entered as Dexamethasone 4 mg (milligram) tablet, give 2 tablets by mouth one time a day for prophylaxis. Take 8 [mg] on days 2 and 3 of treatment was an entry error. The medication was supposed to be ordered as Dexamethasone 4 mg tablet, give 2 tablets on day 2 and 3 after chemo treatment. This was a medication error because it was entered incorrectly and but not a significant medication error. Facility provided policy titled Medication Administration dated November 2021 showed 5. check medication administration record prior to administering medication for the right medication, dose, route, patient, time, reason, response, and documentation . 8. If there is a discrepancy between the MAR and the label, check the orders before administering the medications . 9 . if the MAR is wrong, reenter the order . 23. If medication is ordered but not present, check to see if it was misplaced and then call the pharmacy to obtain the medication. If available obtain from the emergency or convenience box. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 2 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 assist residents identified as needing assistance with personal hygiene. Residents Affected - Some This applies to 6 of 6 residents (R9, R13, R15, R35, R42 and R264) reviewed for ADL (activities of daily living) in the sample of 19. The findings include: 1. R9 has multiple diagnoses which includes chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic neuropathy, osteoarthritis, Parkinson's disease and dementia without behavioral disturbance, based on the face sheet. R9's quarterly MDS (Minimum Data Set) dated November 10, 2022, showed that the resident is moderately impaired with cognition. The same MDS showed that R9 required extensive assistance from the staff with most of her ADLs, including personal hygiene. On January 9, 2023, at 12:21 PM, R9 was in bed, alert and verbally responsive. R9's fingernails were long with black substances underneath. R9 stated that she wants the staff to clean and trim her fingernails. V4 (LPN/Licensed Practical Nurse) was informed of the condition of R9's fingernails. V4 stated, Resident would scratch herself, she should have her fingernails short. R9's active care plan showed that the resident has an ADL self-care performance deficit. 2. R13 has multiple diagnoses which includes senile degeneration of brain and osteoarthritis, based on the face sheet. R13's significant change in status MDS dated [DATE], showed that the resident is severely impaired with cognition. The same MDS showed that R13 required extensive assistance with most of her ADL, including personal hygiene. On January 9, 2023, at 10:56 AM, R13 was sitting in her wheelchair inside her room. R13 was alert but confused and would respond to simple questions only. R13's fingernails were long, jagged with black substances underneath. V5 (CNA/Certified Nursing Assistant) was present during the observation. R13's active care plan showed that the resident has an ADL self-care performance deficit. 3. R15 has multiple diagnoses which includes chronic diastolic (congestive) heart failure, dysphagia (oral phase), protein-calorie malnutrition, developmental disorder of scholastic skills, cerebrovascular disease and dementia without behavior disturbance, based on the face sheet. R15's significant change in status MDS dated [DATE], showed that the resident is severely impaired with cognitive skills for daily decision making. The same MDS showed that R15 required extensive assistance from the staff with most of her ADLs including personal hygiene. On January 9, 2023, at 11:18 AM, R15 was in bed, awake but non-verbal. R15's fingernails were long, jagged and with black substances underneath. V4 (LPN) who was present during the observation stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 3 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 0677 that R15's fingernails needed cleaning and trimming. Level of Harm - Minimal harm or potential for actual harm R15's active care plan showed that the resident has an ADL self-care performance deficit. Residents Affected - Some 4. R42 has multiple diagnoses which includes type 2 diabetes mellitus with diabetic nephropathy, giant cell arteritis with polymyalgia rheumatica and morbid (severe) obesity due to excess calories, based on the face sheet. R42's annual MDS dated [DATE], showed that the resident is cognitively intact. The same MDS showed that R42 required extensive assistance from the staff with most of his ADLs, including personal hygiene. On January 9, 2023, at 10:44 AM, R42 was in bed, alert and verbally responsive. R42's fingernails were long, jagged with black substances underneath. R42 stated that he wants the staff to clean and trim his fingernails. V3 (Assistant Director of Nursing) was informed of R42's fingernails and the request of the resident. R42's active care plan showed that the resident has an ADL self-care performance deficit. On January 11, 2023, at 11:14 AM, V2 (Director of Nursing) stated that it is part of the facility's nursing care to clean and trim all residents' fingernails, especially for those residents' needing assistance, to maintain personal hygiene. The facility's fingernail care guideline dated September 2013 showed in-part, 1. Resident fingernails will be inspected during morning and evening ADL care, for cleanliness, length, and that no sharp or jagged edges are present. 2. Hand hygiene will be performed with ADL care and as needed to ensure nails are clean. 3. If nails are long or have sharp/jagged edges, the nails are to be trimmed.6. Clean the resident's nails. 5. The EMR (Electronic Medical Record) showed R35 was admitted to the facility on [DATE], with multiple diagnoses including dementia, dysphagia, and pubic fracture. R35's MDS (Minimum Data Set) dated November 9, 2022, showed R35 has severe cognitive impairment and required extensive assistance from facility staff for personal hygiene. On January 9, 2023, at 10:37 AM, R35 was sitting in her wheelchair in her room. R35's nails were long, cracked, and jagged. R35 said I do not like my nails long, I would like them cut. On January 10, 2023, at 3:50 PM, R35 was sitting in her wheelchair in the hallway. R35's nails were long, cracked, and jagged. R35 said, I got my hair washed, but my nails are not cut. 6. The EMR showed R264 was admitted to the facility on [DATE], with multiple diagnoses including morbid obesity, diabetes, congestive heart failure, lymphedema, and cellulitis of buttock. R264's MDS dated [DATE], showed R264 was cognitively intact. The MDS continued to show R264 has a limitation in range of motion on both lower extremities, was not steady and only able to stabilize with staff assistance when making surface-to-surface transfers and uses a wheelchair for mobility. The MDS showed R264 required extensive assistance of facility staff for personal hygiene and bathing did not occur during the MDS observation period. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 4 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On January 9, 2023, at 11:08 AM, R264 was in his room, lying in bed. R264 appeared unkempt and R264's hair had a wet, greasy appearance. R264 said, My hair is not wet, it is greasy. I do not get showers, I get bed baths, and they have a hard time washing my hair when I am in bed. I do not get bed baths twice a week and sometimes I do not get them once a week. I would like to be bathed at least twice a week, I am supposed to get them on Wednesdays and Saturdays. I would like to take a shower, but I was told I cannot get into the shower room because I require a [full body mechanical lift]. On January 11, 2023, at 1:02 PM, V2 (DON/Director of Nursing) said, [R264] can have a shower if he wants one, there is no reason he cannot have one. The facility provided documentation dated January 11, 2023, to show R264 received baths on the following dates: October 26, 2022 November 2, 2022 November 5, 2022 November 9, 2022 November 18, 2022 November 23, 2022 November 26, 2022 November 30, 2022 December 7, 2022 December 10, 2022 December 20, 2022 December 21, 2022 December 24, 2022 January 4, 2023 January 7, 2023 The facility does not have documentation to show R264 received two showers and/or bed baths a week as per the facility policy and as per R264's preference. The facility policy titled, BATHING, revised on 5/21 showed Responsible Party: RN (Registered Nurse), LPN (Licensed Practical Nurse), and Certified Nursing Assistant. Guideline: 1. All residents are given a bath or shower at least once per week, based on resident preference, by the Certified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 5 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 0677 Nursing Assistant. 2. If a resident requires a bed bath, a complete bed bath is given two times per week, and a partial bed bath the other days. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 6 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 Based on observation, interview, and record review, the facility failed to assess and provide an intervention for a resident who has a history of Moisture-Associated Skin Damage (MASD). This applies to 1 of 19 residents (R30) reviewed for care and treatment in the sample of 19. Residents Affected - Few The findings include: 1. The Face sheet shows that R30 is 79 years-old with multiple medical diagnoses including weakness and history of pressure ulcer in the sacral region. R30's MDS (Minimum Data Set) dated 12/18/22 shows that R30 is alert and oriented and requires extensive assistance for mobility and toileting. On 1/9/23 at 2:15 PM, R30 was sitting in her wheelchair. She (R30) stated that she has been waiting for a staff to assist her back to bed and to change her incontinence brief. R30 also said that the last time they changed her was after breakfast between 8:30 AM and 9:00 AM. R30 felt that she was forgotten, and she also felt some pain and discomfort on her buttocks. On 1/9/23 at 2:32 PM, V24 (Certified Nursing Assistant/CNA) and V26 (Nurse) transferred R30 from the wheelchair to the bed. At 2:37 PM, V24 rendered incontinence care to R30 who was wet with urine and had a bowel movement. There was an open wound on the left buttock. R30 asked V24 how was her wound on her left buttock doing, to which V24 responded Not too bad. The wound bed was pink in color and surrounding area of the wound was pale and skin was peeling. V24 (CNA) proceeded to provide incontinence care. On 1/9/23 at 2:45 PM, V17 (Wound Care Nurse) came into the room and asked R30 how she felt in her buttock region. R30 said that she has a burning sensation with a pain of 7 out of 10 (Pain scale of 0 to 10, 0 means no pain and 10 means the worst pain possible). V17 said she has been watching R30's skin on the buttocks because R30 has a moisture-associated skin damage (MASD) which opened just now. V17 measured it as Length (L) 1 centimeter (cm) x Width 1.1 cm x Depth 0.1 cm. V17 cleansed the wound with normal saline solution (NSS) then she applied Z-guard. V17 also stated that R30's daughter told her that R30's skin is thin and sensitive and tends to breakdown easily. On 1/9/23 at 3:33 PM, R30 stated that she had known that she had a sore on her left buttock for 2 weeks because she felt it and the staff has been telling her too. On 1/9/23 at 3:37 PM, V24 (CNA) stated that he's not sure when R30's wound started but it has been there since last week. On 1/10/23 at 1:56 PM, V23 (CNA) stated that the wound on R30's left buttock has been there a while. It was a wound that was re-opened but it re-opened a while ago. V23 was unable to recall when it exactly opened, but it was already there since last week. On 1/11/23 at 3:55 PM, V2 (Director of Nursing) stated that the staff are to do unit rounds every 2 hours to check for incontinence and change as needed. R30's record does not have evidence to show that R30 was assessed prior to the observation on 1/9/23, even though V17, V23, and V24 knew that she has MASD. In addition, R30 also waited almost 5 hours before she was checked and changed for incontinence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 7 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R15 has multiple diagnoses which includes obstructive and reflux uropathy, chronic diastolic (congestive) heart failure, developmental disorder of scholastic skills, cerebrovascular disease, and dementia without behavior disturbance, based on the face sheet. R15's significant change in status MDS (minimum data set) dated November 29, 2022, showed that the resident is severely impaired with cognitive skills for daily decision making. The same MDS showed that R15 required extensive assistance from the staff with most of her ADL (activities of daily living), including toilet use and personal hygiene. On January 9, 2023, at 11:18 AM, R15 was in bed, alert but non-verbal. R15 had a strong urine odor. R15's bed was on the lowest position. Part of R15's urinary catheter tubing and the resident's privacy bag containing the urinary catheter drainage bag was resting on the floor. V4 (LPN/Licensed Practical Nurse) was present during this observation. On January 10, 2023, at 12:24 PM, R15 was in bed. R15's had a strong urine odor. R15's bed was on the lowest position. Part of R15's urinary catheter tubing and the resident's privacy bag containing the urinary catheter drainage bag was resting on the floor. On January 10, 2023, at 12:34 PM, V6 (CNA/Certified Nursing Assistant) stated that R15 has a strong urine odor. According to V6 she last checked and changed R15 at around 10:30 AM that morning and during that time, she also noticed that R15's brief was slightly wet with urine. V6 proceeded to check R15's disposable brief and noted that the brief was wet with urine. V6 unfastened the resident's disposable brief, then proceeded to turn R15 on her left side (towards the window). V6 with her gloved hands, cleaned R15's anal and buttock areas using disposable cleansing cloths. R15 had a small amount of stool. After cleaning R15's anal and buttock areas and while R15 was turned on her left side, V6 applied a new disposable brief under the resident, turned R15 on her back, cleaned R15's left and right groin and thigh areas. V6 did not clean R15's pubic area and did not separate the resident's labial folds to clean. V6 also did not clean the resident's catheter insertion site. 4. R114 was admitted to the facility on [DATE]. R114 has multiple diagnoses which includes wedge compression fracture of the first lumbar vertebrae, chronic kidney disease (stage 3) and history of UTI (urinary tract infection), based on the face sheet. R114's skilled service documentation dated January 9, 2023, showed that the resident is cognitively intact. The same skilled service documentation showed that R114 required extensive assistance from the staff with toilet use. On January 10, 2021, at 9:04 AM, R114 requested to use the bedpan. V4 (LPN) offered the bedpan to the resident. At 9:06 AM, with her (V4) gloved hands, while removing the bed pan, some of the urine spilled on R114's folded sheets underneath the resident. While R114 was turned on her left side, V4 used disposable cleansing cloths and cleaned R114's back and buttock areas. V4 then applied and fastened the new disposable brief on R114 without cleaning the resident's front perineal area. On January 11, 2023, at 11:18 AM, V2 (Director of Nursing) stated that for all resident's needing assistance for toilet use, whether continent or not, should be cleaned from front to back, including (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 8 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the entire perineal area and back/buttocks areas. For residents with indwelling urinary catheter, the nursing staff should clean from the insertion site going outwards and for female residents, the labial folds should be separated. According to V2, all of the above procedures should be performed to maintain the resident's hygiene and prevent urinary infection. On January 11, 2023, at 5:05 PM, V2 stated that the resident's urinary catheter tubing and the privacy bag containing the urinary drainage bag should not be touching and/or resting on the floor to prevent infection. The facility's incontinence care guideline dated October 2003 showed, Incontinence care is provided to keep residents as dry, comfortable and odor free as possible. The facility's undated tool for validation of competency regarding perineal care showed in-part, For female resident: Wash in the direction of the pubis toward the perineum and dry from to bottom. The facility's indwelling catheter care and maintenance guideline dated September 2013 showed in-part under care of indwelling catheter, 2. Keep the drainage bag below the level of resident's bladder and 3. Keep the drainage bag off of the floor. Based on observation, interview, and record review, the facility failed to provide perineal and indwelling urinary catheter care in a manner that would promote hygiene and prevent urinary tract infection. The facility also failed to ensure that a catheter bag and catheter tubing was not touching the floor. This applies to 4 of 6 residents (R15, R19, R30, R114) reviewed for perineal and urinary catheter in the sample of 19. The findings include: 1. On 1/10/23 at 12:54 PM, V23 (Certified Nursing Assistant/CNA) rendered incontinence care to R30 who was wet with urine and had a small bowel movement. V23 wiped R30's outer labia but did not open the labial folds to clean the inner area. 2. R19 is 80 years-old with multiple medical diagnoses including obstructive and reflux uropathy, urinary tract infection (UTI), infection and inflammatory reaction to indwelling urethral catheter, subsequent encounter, and retention of urine. On 1/10/23 at 1:03 PM, V23 (CNA) rendered perineal and indwelling urinary catheter care to R19. The urinary tubing showed amber colored urine with sedimentation. V23 lifted R19's urinary bag above the resident's body to check R19's urine output. The urine in the catheter tube moved, flowing downward towards R19. On 1/10/23 at 1:12 PM, V23 rendered peri-care. V23 cleaned R19 from front to back. However, V23 did not clean the catheter from the point of entry down to his thigh by the anchor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 9 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician. There were 27 opportunities with 2 errors, resulting in a 7.41% medication error rate. Residents Affected - Few This applies to 1 of 4 residents (R28) observed during the medication pass in the sample of 19. The findings include: On January 10, 2023, at 9:25 AM, V4 (Licensed Practical Nurse) prepared and administered multiple medications to R28, including Metoprolol Succinate ER (extended release) 50 mg, 1 tablet and Losartan Potassium 100 mg, 1 tablet. R28 has multiple diagnoses which included essential (primary) hypertension, presence of cardiac pacemaker, chronic diastolic (congestive) heart failure, dementia without behavioral disturbance and Alzheimer's disease, based on the face sheet. R28's physician order report shows an active order dated January 6, 2023, for Metoprolol Succinate ER 25 mg, 1 tablet by mouth one time a day related to hypertension and Losartan Potassium 50 mg, 1 tablet by mouth one time a day related to hypertension. R28's MAR (medication administration record) dated January 10, 2023, showed documentation created by V4 that she administered Metoprolol Succinate ER 25 mg, 1 tablet by mouth and Losartan Potassium 50 mg, 1 tablet by mouth during the 9:00 AM medication pass. On January 10, 2023, at 2:40 PM, V4 showed the available used blister packs of Metoprolol Succinate ER 50 mg and Losartan Potassium 100 mg for R28, which were both filled by the pharmacy on December 16, 2022. V4 stated that she gave one tablet of Metoprolol Succinate ER 50 mg and one tablet of Losartan Potassium 100 mg to R28 during the 9:00 AM medication pass while being observed by the State agency representative. V4 was informed that based on the active physician order report, R28 had different dosage orders for the above-mentioned medications. V4 reviewed the electronic order report for R28 and admitted that she gave the wrong dosage for the Metoprolol and Losartan medications. On January 11, 2023, at 12:16 PM, V12 (Physician) stated that she was informed about the double dosing of the Metoprolol and Losartan for R28 on January 10, 2023. V12 stated that the medication error was not acceptable. V12 further stated that she expects the facility to follow her ordered medications for R28. The facility's medication administration guideline dated October 2003 showed, All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. The same medication administration guideline showed multiple guidelines which includes, 1. An order is required for administration of all medication. 5. Check medication administration record prior to administering medication for the right medication, dose, route, patient time, reason, response, and documentation. 6. Read each order entirely. 7. Remove medication from drawer and read label three times. 8. If there is a discrepancy between the MAR (medication administration record) and label, check orders before administering medications. 14. Document as each medication is prepared on the MAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 10 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer a steroid inhaler as ordered by the physician for a resident who has Chronic Obstructive Pulmonary Disease (COPD). This applies to 1 of 19 residents (R34) reviewed for medications in the sample of 19. Residents Affected - Few The findings include: On 1/11/23 at 10:44 AM, V8 (Nurse) administered multiple medications to R34 which included Wixela Fluticasone-Salmeterol 100-50 microgram (mcg)/actuation (act). Prior to administration, state agency representative checked each of R34's medication to reconcile what was being given. It was noted that the Fluticasone-Salmeterol was opened on 12/30/22. This same medication has a total of 60 actuations (dosages) if unopened. The actual remaining doses (actuations) on 1/11/23 at 10:40 AM was 55 (according to the counter window), which means that only 5 doses were used by or administered to R34. When V8 administered the Fluticasone-Salmeterol to R34, he (R34) frowned and stated that he doesn't care much for this medication. State agency representative noted that this Wixela (Fluticasone-Salmeterol) is round, it has a lever/indentation to open the mouthpiece, which is the opening of the medication container. Beside the mouthpiece, there is another lever which needs to be pulled down to release the powdered medication. On 1/11/23 at 2:35 PM, R34 clarified what he meant about the above comment he made. R34 stated that he doesn't like this Wixela medication (Fluticasone-Salmeterol) because sometimes he could taste it coming in and sometimes, he cannot, he is not sure if this medication is really working for him. The pharmacy receipt shows that the Wixela Inhub Inhalation Aerosol Powder Breath Activated 100-50 mcg/act (Fluticasone-Salmeterol 100-50 mcg/act) was ordered on 12/15/22 with a start date of 12/16/22 at 10:00 AM. This medication was delivered by the pharmacy on 12/16/22 at 3:41 AM with an instruction to administer 1 puff orally once a day for Chronic Obstructive Pulmonary Disease. R34's most recent physician order (POS) of Wixela Inhub Inhalation Aerosol Powder Breath Activated 100-50 mcg/act (Fluticasone-Salmeterol) dated 1/5/23 shows to administer 1 puff inhale orally two times a day for COPD. The Medication Administration Record (MAR) dated December 2022 shows that this Wixela Inhub was started on 12/22/22 and was signed as given daily. While the MAR dated January 2023 shows that this medication was signed as given daily from 1/1/23 through 1/4/23 and from 1/5/23 it was signed as given twice daily. R34 should have received 32 doses of the inhaler but only 5 doses were given as per the counter window. On 1/11/23 at 1:16 PM, V2 (Director of Nursing/DON) stated that R34 came from the hospital. R34 had no medications with him when he arrived at the facility. R34's medications were all delivered by the pharmacy. On 1/11/23 at 4:15 PM, V2 also said that she was not sure why there were 55 doses remaining in the container of Wixela, the only reason that she could think of was that the staff did not slide the second lever of the Wixela which releases the medication to R34. On 1/11/23 at 2:14 PM, V12 (Physician) stated that she increased the dose of R34's Wixela (Fluticasone-Salmeterol) inhaler because she discontinued his Symbicort inhaler. V12 prescribed R34 the Wixela due to diagnosis of COPD. The facility has a protocol for COPD. They prescribe inhaler with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 11 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 0760 Level of Harm - Minimal harm or potential for actual harm long-acting effect and an inhaler as rescue dose. There is also steroid inhaler which is prescribed only for those people with serious COPD to keep the inflammation down. R34 has serious COPD that is why he was prescribed the Wixela. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 12 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to serve food in a sanitary manner to prevent cross contamination. This applies to all 70 residents that consume meals orally. Residents Affected - Many The Findings include: The facility census list of January 9, 2023, documents 71 residents in the facility. V2 (Director of Nursing/DON) stated during an interview of January 12, 2023, at 3:55PM that only one resident is NPO (Nothing Per Oral) in the facility. On January 9, 2023, at 12:09 PM, V16 (Cook) was observed preparing and plating food from the steam table. The menu was Tuscan chicken breast, spaghetti noodles, mixed vegetables, garlic toast. V16 was observed using tongs for the spaghetti noodles and then using his gloved hand to place noodles on the plate. At times V16 was noted to use his gloved hands to pick up the chicken and move the noodles onto to the plate. V16 was observed to garnish the plate of chicken, noodles, and vegetables by dipping his hand into the container of parmesan cheese. V16 would wipe his gloved hands on his soiled apron and adjust his facial mask throughout the lunch meal. V16 did not change his gloves or wash his hands during this observation. V15 (Food Service Director) confirmed during interview of January 11, 2023, at 12:50 PM that when serving food, staff must use serving utensils for each food item to prevent cross contamination. V15 also added that using gloved hands to serve food in not an appropriate technique. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 13 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. R15 has multiple diagnoses which includes obstructive and reflux uropathy, chronic diastolic (congestive) heart failure, developmental disorder of scholastic skills, cerebrovascular disease, and dementia without behavior disturbance, based on the face sheet. Residents Affected - Some R15's significant change in status MDS (minimum data set) dated November 29, 2022, showed that the resident is severely impaired with cognitive skills for daily decision making. The same MDS showed that R15 required extensive assistance from the staff with most of her ADL (activities of daily living), including toilet use and personal hygiene. On January 10, 2023, at 12:34 PM, V6 stated that R15 smelled of strong urine odor. R15 had an indwelling urinary catheter. V6 checked R15's disposable brief and noted that R15's disposable brief was wet with urine. V6 stated that she will change R15's brief before feeding R15 for lunch. V6 unfastened the resident's disposable brief, then proceeded to turn R15 on her left side (towards the window). V6 with her gloved hands, cleaned R15's anal and buttock areas using disposable cleansing cloths. R15 had a small amount of stool. After cleaning R15's anal and buttock areas and while R15 was turned on her left side, V6 applied a clean disposable brief under the resident using the same soiled gloves that she used to clean the resident. After applying the clean disposable brief, V6 turned R15 on her back, cleaned R15's left and right groin and thigh areas using disposable cleansing cloths, fastened the disposable brief and repositioned R15 in bed while still wearing the same soiled gloves. After this procedure, V6 removed her soiled gloves and with her bare hands she took the plastic garbage bag (containing the used disposable brief and used disposable cleansing cloths) from the trash can, tied the garbage bag, throw the garbage bag inside the housekeeping cart, and stated that she will call another staff to help with raising R15 in bed. V6 did not perform hand hygiene (hand washing or use of hand sanitizer). V6 went to the office area and asked the assistance of V7 (Nurse Consultant). V6 and V7 went inside R15's room, put on new pair of gloves and repositioned R15 in bed. After repositioning R15, V6 removed her gloves, used hand sanitizer then started feeding R15. 6. R114 was admitted to the facility on [DATE]. R114 has multiple diagnoses which includes wedge compression fracture of the first lumbar vertebrae, chronic kidney disease (stage 3) and history of UTI (urinary tract infection), based on the face sheet. R114's skilled service documentation dated January 9, 2023, showed that the resident is cognitively intact. The same skilled service documentation showed that R114 required extensive assistance from the staff with toilet use. On January 10, 2021, at 9:04 AM, R114 requested to use the bedpan. V4 (Licensed Practical Nurse) offered the bedpan to the resident. At 9:06 AM, with her (V4) gloved hands, while removing the bed pan, some of the urine spilled on R114's folded sheets underneath the resident. While R114 was turned on her left side, V4 used disposable cleansing cloths and cleaned R114's back and buttock areas. V4 then applied the clean disposable brief on R114 while still wearing the same gloves. V4 proceeded to assist R114 in repositioning while in bed, used the bed control to slightly raise the head of the resident's bed and placed the resident's phone on top of the overbed table, while still wearing the same gloves that she used to clean R114. V4 then removed her gloves, took the plastic garbage bag (containing the used disposable brief and used disposable cleansing cloths) from the trash can, tied the said bag and proceeded to leave the room without performing hand hygiene. V4 used her bare right hand to turn the room doorknob and then used her bare hand to turn the soiled utility room doorknob. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 14 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 V7 went inside the soiled utility room and discarded the garbage bag. Level of Harm - Minimal harm or potential for actual harm On January 11, 2023, at 11:18 AM, V2 (Director of Nursing) stated that during provision of care from dirty to clean, the staff's used/soiled gloves should be removed, hand hygiene either hand washing, or use of hand sanitizer should be performed and then re-gloved to continue the care. V2 stated that the staff should not use the same used or soiled gloves (after cleaning the resident) to reposition the resident, to handle clean supplies like brief or equipment like phone and bed control. V2 stated that to perform hand hygiene, the staff should wash their hands after removing gloves and before re-gloving after soiling their gloves. According to V2, the staff may use hand sanitizer if the resident does not have C-diff (Clostridium difficile) and if their gloves or hands are not soiled. V2 stated that before the staff started feeding R15, the staff should have washed her hands and should have washed her hands in between perineal/ incontinence care from dirty to clean procedure, for infection control and to prevent cross contamination. V2 further stated that hand hygiene (either hand washing or use of hand sanitizer) should have been performed before the staff touched the doorknob after removing her gloves and touching the trash bag for infection control and to prevent cross-contamination. Residents Affected - Some The facility's hand hygiene guideline dated June 17, 2022, showed, Infection prevention practices centered on hand hygiene protocols can save lives across all healthcare facilities. Facility supports practicing hand hygiene, which includes the use of alcohol-based hand rub or handwashing to prevent the spread of pathogens and infections in healthcare settings. The guideline showed in-part that during routine patient care, the use of an alcohol-based hand sanitizer or washing hands with soap and water should be performed, v. Before moving from work on a soiled body site to a clean body site on the same patient and ix. Immediately after glove removal. The guideline under when and how to perform hand hygiene it showed, Multiple opportunities for hand hygiene may occur during a single care episode. The same guideline showed in-part under glove use, b. Gloves are not substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves. c. Change gloves and perform hand hygiene during patient care, if gloves become visibly soiled with blood or body fluids following a task, moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. 4. On 1/11/23 at 9:37 AM, V8 and V22 (Both Nurses) rendered incontinence care to R166. V22 cleaned R166 from front to back. After providing peri-care, V22 applied clean incontinence brief, pushed the wet wipes that was sticking out back into its container, and adjusted R166's shirt while wearing same soiled gloves. On 1/11/23 at 3:28 PM, V2 (DON) stated that when providing incontinence care, the staff must wash hands before starting and after providing care. During provision of care, the staff should wear clean gloves, remove gloves, and perform hand hygiene prior to proceeding to clean task. Based on observation, interview, and record review the facility failed to follow their policy on changing gloves and hand hygiene when providing care to residents and when exiting isolation rooms. The facility failed to ensure isolation and non-isolation rooms are not cleaned using the same cleaning supplies. This applies to 7 of 19 residents (R3, R15, R26, R43, R114, R166, R216) reviewed for infection control practices in a sample of 19. The findings include: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 15 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. R3's EMR (Electronic Medical Record) showed R3's diagnoses included weakness, chronic obstructive pulmonary disease, congestive heart failure, and peripheral vascular disease. The physician order showed an order dated January 3, 2023, for Contact isolation due to c-diff (Clostridium Difficile) On January 10, 2023, at 8:11 AM, V14 (Housekeeper) was observed standing in the doorway of R3's room wearing an isolation gown, gloves, face shield, and surgical mask. The signage on the room door showed R3 was in Contact Isolation. There was an over the door caddy containing gowns and gloves. V14's housekeeping cart was in the open doorway and V14 was observed coming to the doorway to get cleaning supplies off the cart. V14 grabbed the toilet brush out of the caddy it was sitting in, used it in the bathroom, and returned it to the caddy hanging on the cart. V14 was observed removing her isolation gown and gloves, V14 came out of the room and used the hand sanitizer from the container hanging on the wall outside of R3's room. V14 was then observed entering R26's room to clean. R26's room was not an isolation room. V14 used the same cleaning supplies that were used in R3's isolation room. V14 then went into R216's room which was not and isolation room and cleaned the bathroom and room using the same cleaning supplies used in R3's isolation room. V14 then went into R43's room after putting on an isolation gown and gloves. V14 was already wearing a surgical mask and face shield. R43's room door signage showed R43 was in Contact Isolation and there was an over the door caddy containing gowns and gloves. V14 used the same cleaning supplies used in at the last three rooms. V14 finished cleaning R43's room, removed her isolation gown and gloves. V14 came out of the room and used the hand sanitizer from the container hanging on the wall outside of R43's room. V14 Never changed the mop water or disinfected the equipment used to clean the isolation rooms before entering a non-isolation room. R43's EMR showed R43's diagnoses included weakness, type 2 diabetes, enterocolitis due to clostridium difficile recurrent, acute kidney failure, and chronic pain. The physician orders dated December 19, 2022 Contact isolation due to c-diff . On January 10, 2023, at 8:48 AM, V14 (Housekeeper) reported she cleans the resident rooms using the same duster mop for three rooms and then will change. The mop that is used is a flat cloth pad that fastens to the bottom of the mop, the cloth pad gets changed after every room. V14 reported she sprays all the rooms with a diluted bleach solution, empty the garbage, and then wipes down the room with her cloth rag. When residents are in isolation V14 reported she uses diluted bleach to clean the bathroom and sprays areas in the room such as the television remote, the nurse call button and over the bed tray table. V14 reported she dumps the toilet brush caddy every fourth rooms. V14 reported she looks at the sign on the door to know what kind of isolation the resident is in. On January 10, 2023, at 8:58 AM, V13 (Environmental Supervisor) reported Covid isolation rooms get cleaned after all other rooms are cleaned and get cleaned twice a day. All other isolation rooms get cleaned first before non-isolation rooms and get cleaned twice a day. If the resident is in isolation for C-Diff (Clostridium Difficile) the room should get cleaned with bleach wipes. V13 reported generally the flat cloth mop gets changed every two to three rooms and then they get sent to laundry. Ideally, they would get changed after every room, but they have a lot of missing flat mop pads and had to order more which have not come in yet. V13 also reported she does not like that the same toilet brush is used in the same rooms but the caddy it sits in has germicidal bleach in it. If the resident is in isolation of c-diff, the housekeeper needs to use soap and water to wash hands and not used hand sanitizer. 2. On (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 16 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 Level of Harm - Minimal harm or potential for actual harm January 11, 2023, at 8:37 AM, V6 (CNA/Certified Nurse Assistant) went into R43's room wearing and isolation gown, gloves, face shield, mask. She came out after she discarded the PPE (Personal Protective Equipment) inside the room including surgical mask and face shield. V6 was carrying a breakfast tray, V6 set the tray on top of treatment cart, used the hand sanitizer from the container on the wall and picked up tray and walked off the unit. Residents Affected - Some On January 11, 2023, at 8:44 AM, V6 put on an isolation gown, gloves, face shield, and surgical mask. V6 went into R43's room with a bedpan and new incontinent brief. V6 removed the gown, gloves, and mask, in the room. V6 exited the room and used the hand sanitizer in the container on the wall. On January 11, 2022, at 8:52 AM, V6 came out of room R43's room. R43 was in contact isolation for c-diff. V6 removed the gown and gloves in the room. V6 used hand sanitizer in hallway. V6 reported she does not know why R3 or R43 are in isolation, but knows they are in contact isolation. V6 also reported if the isolation is c-diff you have to use soap and water and not hand sanitizer to clean hands after care and when exiting the room. 3. On January 11, 2023, at 8:54 AM, V8 (LPN/Licensed Practical Nurse) went into R3's room wearing gown, gloves, face shield and mask, when she came out of the room, she had removed the gown and gloves in the room and used the hand sanitizer in room. V8 reported R3 and R43 are both in isolation for c-diff and she should use soap and water for hand hygiene and not hand sanitizer. On January 11, 2023, at 9:11 AM, V2 (Director of Nursing) reported if a resident is in isolation for c-diff, the staff have to use soap and water, they cannot use hand sanitizer. The CNAs and nurses need to communicate what kind of isolation the resident is in. If a resident is placed into isolation, the nurse needs to let the CNAs know. If the CNA does not know why someone is in isolation, they need to ask the nurse. Facility provided their undated policy titled Isolation Room Cleaning Procedures showed . 10. mop water MUST be changed after completing the isolation room procedure. Disinfect all tools utilized to clean the room using EPA approved solution. Wash hands and arms using the proper hand washing technique. Facility provided their policy titled Clostridiodes Difficile (formally Clostridium Difficile) with revision date of November 2021. The policy showed the facility promotes a safe environment through the Infection Control Program designed to prevent the spread of infectious disease . Spores of Clostridium difficile can be acquired from the environment or by fecal-oral transmission (unwashed hands) from colonized or infected individuals . 5. Following hand hygiene practices, including before seeing a resident and after removal of gloves (with soap and water). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 17 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 follow physician's order to administer a pneumococcal vaccine. Residents Affected - Few This applies to 1 of 5 residents (R36) reviewed for pneumococcal vaccinations in a sample of 19. The findings include: The EMR (Electronic Medical Record) showed R36 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, rheumatoid arthritis, and long term steroid use. R36's MDS (Minimum Data Set) dated December 25, 2022, showed R36 was cognitively intact. On January 11, 2023, at 1:08 PM, V3 (ADON/Assistant Director of Nursing) said, [R36] consented for the Prevnar 20 pneumococcal vaccine on January 4, 2023. We did not have the vaccine at that time, but we have it now. On January 11, 2023, at 1:47 PM, V2 (DON/Director of Nursing) said, We received the Prevnar 20 vaccine on January 6, 2023. All floor nurses are able to administer the vaccine. [R36] should have received her Prevnar 20 vaccine sooner. The facility document titled, Consent for Pneumonia Vaccine . showed R36 consented to vaccination on January 4, 2023. R36's order dated January 4, 2022, showed Prevnar 20 Suspension Prefilled Syringe 0.5 mL (milliliter). Inject one dose intramuscularly one time only for pneumonia vaccine . The facility provided R36's January 2023 MAR (Medication Administration Record) on January 11, 2023, at 4:40 PM. R36's January 2023 MAR did not show documentation R36 received the Prevnar 20 pneumococcal vaccine. The facility policy titled, Pneumococcal Vaccination reviewed on 6/22 showed, General: The most effective way to treat pneumococcal disease it to prevent it through immunization. Responsible Party: admission Department, Nursing. Guideline: . 2. Nurse will provide education regarding pneumococcal vaccination, and administer the vaccine when indicated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 18 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 0887 Level of Harm - Minimal harm or potential for actual harm Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy to offer residents the COVID-19 vaccine. Residents Affected - Some This applies to 4 of 5 residents (R31, R215, R36, and R4) reviewed for COVID-19 vaccinations in a sample of 19. The findings include: 1. R31's EMR (Electronic Medical Record) showed R31 was admitted to the facility on [DATE]. The facility does not have documentation to show the facility offered R31 the COVID-19 vaccine. 2. R215's EMR showed R215 was admitted to the facility on [DATE]. The facility does not have documentation to show the facility offered R215 the COVID-19 vaccine. 3. R36's EMR showed R36 was admitted to the facility on [DATE]. The facility does not have documentation to show the facility offered R36 the COVID-19 vaccine. 4. R4's EMR showed R4 was admitted to the facility on [DATE]. The facility does not have documentation to show the facility offered R4 was offered the COVID-19 vaccine. On January 11, 2023, at 12:23 PM, V1 (Administrator) said, The last COVID-19 vaccination clinic the facility had was in May 2022. The clinics in October 2022 and November 2022 were canceled because the facility was in COVID-19 outbreak status, and most residents had COVID-19. We do not offer the COVID-19 vaccine to residents until 24 to 48 hours before the COVID-19 vaccine clinic. The facility policy titled Coronavirus Vaccine - Residents revised on 2.14.2022 showed Purpose: Maximizing COVID-19 vaccination rates in the facility will help reduce the risk residents and staff have of contracting and spreading COVID-19. The purpose of this policy and procedure (P and P) is to outline the facility approaches to encourage residents to receive a COVID-19 vaccine. Responsibility: Nursing home leadership is responsible for developing, implementing, and maintaining these policies and procedures . Obtaining COVID-19 Vaccine: -COVID-19 vaccine will be ordered from either our LTC (Long Term Care) pharmacy or local or state public health agency or arrangements will be made with a vaccine provider to administer the vaccine to residents. -In case of lack of availability of the COVID-19 vaccine, or other issue with the availability leading to an inability to implement the COVID-19 vaccine program, the facility will demonstrate that attempts to order vaccines have been exhausted, including LTC pharmacies and the state health department. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 19 of 20 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 146034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl at the Tillers 4390 Route 71 Oswego, IL 60543 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 0887 Educating Residents on the COVID-19 Vaccine: Level of Harm - Minimal harm or potential for actual harm -COVID-19 vaccination will be offered to all residents (or their representative if they cannot make health care decisions) unless such immunization is medically contraindicated per CDC (Center for Disease Control and Prevention) guidance, or the individual has already been immunized . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146034 If continuation sheet Page 20 of 20