Inspection visit
Health inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on observation, interview, and record review, the facility failed to provide a dignified dining
experience. This applies to 1 of 2 residents (R18) reviewed for dignity in a sample of 69.
Residents Affected - Few
The findings include:
On 2/6/24 at 12:16 PM (during lunch), in the dining room, R18 was sitting in a motorized wheelchair. Both
of her hands were contracted. She was unable to talk. R18 was sitting at the same table as R34. At 12:18
PM, V3 (CNA-Certified Nursing Assistant) placed 2 glasses of juice and 2 small bowels of banana pudding
on the table for R18 and R34. R18 was not able to hold the glass of juice and bowel of banana pudding by
herself. R34 was able to drink the juice and eat her banana pudding independently, which she was doing in
front of R18. There were several other residents in the dining room that were drinking their juice and eating
their banana pudding independently. V3 did not assist R18 with drinking her juice or eating her banana
pudding. At 12:20 PM, V3 gave R34 a tray of scrambled eggs and bread. R34 started eating her food in the
presence of R18 who did not get her tray. Surveyor asked R18 if it bothered her that she didn't get her tray,
even though R34 did. R18 did not reply because she was nonverbal and just stared at R34. At 12:35 PM,
R18 received her tray of pureed food and was finally fed by V3 at 12:38 PM.
On 2/7/24 at 12:28 PM, R18 was sitting in the dining room. She was sitting at a table by herself for a few
minutes alone. At 12:30 PM, staff passed out juice to R18 and other residents in the dining room. No one
assisted R18 to drink her juice. It was not until 12:41 PM that V4 (CNA) came and assisted her with feeding
and helped her drink the juice.
On 2/7/24 at 3:14 PM, V1 (Administrator) stated, They (residents) need to eat together so that's why they
should be served at the same time. It's a dignity issue. A resident shouldn't just watch while another
resident is eating or drinking while waiting for their tray.
R18's face sheet shows an admission date of 2/14/2018. R18's face sheet shows the following diagnoses:
unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood
disturbance, and anxiety, degenerative disease of nervous system, stiffness of left/right hand,
polyneuropathy, and polyosteoarthritis. R18's POS (Physician Order Sheet) shows an order of General diet,
Pureed texture, Regular (Thin) consistency. R18's MDS (Minimum Data Set) dated 1/9/2024 shows a blank
score for her BIM's (Brief Interview for Mental Status) score because she is rarely or never understood. It
also shows that she is severely impaired in making decisions. She has impairment on both sides of her
upper and lower extremity. Under eating she is dependent on staff to use utensils to bring food and/or liquid
to her mouth and swallow food and/or liquid once the meal is placed before R18. R18's care plans show
that she is nonverbal, has a swallowing problem related to holding
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 12
Event ID:
146034
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
02/09/2024
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 0550
food in her mouth/cheeks (pocketing) and intervention to assist resident with feeding.
Level of Harm - Minimal harm
or potential for actual harm
Facility's policy tiled Meal Service (12/2023) documents the following: 9. Trays are delivered to the residents
at the same table at the same time. 11. Residents are encouraged to eat by all facility staff. If a resident
needs to be fed, they are fed.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146034
If continuation sheet
Page 2 of 12
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
02/09/2024
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
Based on observation, interview and record review, the facility failed to ensure that anti-contracture devices
were applied as ordered. This applies to 1 of 3 residents (R34) reviewed for anti-contracture devices in a
sample of 23.
The findings include:
On 2/6/24 at 10:18 AM, R34 was sitting in the wheelchair by the window in her room. R34's left hand was
on her lap, and it was contracted into a fist. No device was in place. R34's 1/18/2024 MDS (Minimum Data
Set) showed that her cognition was intact. R34 said that she fell at home, and she hurt her arms and legs.
At 12:50 PM, R34 was observed eating lunch in the dining room. Her left hand remained in a fist position,
and no device was in place.
On 2/7/24 at 9:51 AM, R34 was sitting in her wheelchair in room. R34's left hand continued to be in fist
position without a device in place. At 2:16 PM, R34 was sitting up in bed, still with her left hand in fist
position and no device in place. R34 said staff does not provide any exercises for her left hand. R34 stated
she used to have a splint on the left hand, but she has not had one on for months.
On 2/8/24 at 9:20 AM, R34 was sitting up in bed with her left hand contracted and no device. R34 said her
left hand feels weak, and staff cannot find the splint for her hand.
R34's EMR (Electronic Medical Record) shows the following diagnoses of hemiplegia and hemiparesis
following cerebral infarction affecting left non-dominant side. R34's February 2024 POS (Physician Order
Sheet) showed an order for a cone splint to her left hand when she is up in a chair. Review of R34's
February 2024 MAR (Medication Administration Review) showed that staff were documenting they were
applying R34's cone splint every shift.
On 2/7/24 at 2:17 PM, V4 (CNA/Certified Nurse Aide) said she is not aware of R34 having a splint, and she
does not have one on when she works with R34.
On 2/7/24 at 2:40 PM, V12 (Restorative Aide) said R34 is not currently on any restorative programs. V12
stated R34 used to be on a passive range of motion program, but since they switched companies, residents
are no longer on any restorative programs except for ambulation. V12 said R34 has a cone splint for the left
hand, and the CNAs are supposed to put it on her when she's sitting up in the chair.
On 2/7/24 at 2:51 PM, V1 (Administrator) provided surveyor the list of residents that use anti-contracture
devices. R34 was on the list.
On 2/8/24 at 11:25 AM, V2 (DON/Director of Nursing) said R34 has a cone splint for her left hand, and she
should have it on when she's up in the chair. The splint is used to prevent contractures or worsening of
contractures.
The facility's Managing Residents with Impaired Physical Mobility policy (review date 3/16/23) states that
the facility will provide care and management of physical mobility impairment and will provide programs to
prevent contractures and or further decline.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146034
If continuation sheet
Page 3 of 12
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
02/09/2024
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 - Few
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** Based on
observation, interview, and record review, the facility failed to position indwelling urinary catheters in a
manner to prevent leakage, failed to cleanse urinary catheter tubing after residents are incontinent, and
failed to ensure incontinent residents were changed in a timely manner to prevent infections. This applies to
3 of 5 residents (R3, R23, and R25) reviewed for bladder and bladder incontinence care in a sample of 23.
The findings include:
1. The EMR (Electronic Medical Record) showed R3 had multiple diagnoses including neuromuscular
dysfunction of the bladder, chronic kidney disease, and chronic pain. The MDS dated [DATE] showed R3
was cognitively intact, incontinent of bowel, and had a urinary indwelling catheter. The MDS continued to
show R3 was dependent on staff with toileting hygiene and required substantial to maximal assistance with
bed mobility from facility staff.
On 2/07/2024 at 11:34 AM, R3 was in bed. V9 (Wound Care Nurse) and V12 (CNA) were positioning R3
after completing wound care. R3's incontinence brief was soiled with urine and her urinary catheter was
positioned underneath her leg, unsecured. V12 said R3's urinary catheter was leaking urine. V9 started to
provide incontinence care to R3, and wiped R3's perineal area from front to back. Then V9 and V12 turned
R3 on her right side and continued to wipe R3's buttock area, and turned R3 on her back and applied a
new incontinence brief. Urinary catheter care was not performed and R3's urinary catheter tubing was left
positioned underneath her leg and unsecured.
2. The EMR showed R23 had multiple diagnoses including urogenital implants, urinary tract infections,
hydronephrosis with renal and ureteral calculous obstruction, neuromuscular dysfunction of the bladder,
and multiple sclerosis. The MDS dated [DATE] showed R23 was cognitively intact, incontinent of bowel, and
had a urinary indwelling catheter. The MDS showed R23 was dependent on staff for toileting and hygiene
and required substantial to maximal assistance with bed mobility from facility staff.
On 2/07/2024 at 3:18 PM, R23 was transferred into bed by V17 (CNA) and V18 (CNA). When V17 and V18
pulled down R23's pants down, the pants were stained with fecal material and R23's incontinence brief was
saturated with stool. V17 started to provide incontinence care to R23 and wiped R23's perineal area. Then
V17 and V18 turned R23 on her right side and continued to wipe R23's buttocks area, then turned her on
her back and continued to clean R23's perineal area again. V17 and V18 applied a new incontinence brief
and did not provide urinary catheter care.
3. The EMR showed R25 had multiple diagnoses including recurrent urinary tract infections, calculus of the
kidney, and weakness. The MDS (Minimum Data Set) dated 12/16/2023 showed R25 was cognitively intact
and had urinary and bowel incontinence. The MDS to showed R25 was dependent on staff for toileting
hygiene and required substantial to maximal assistance with bed mobility.
On 2/07/2024 at 9:54 AM, R25 was in bed. R25 said she was last changed around 6:00 AM and needed to
be changed again. At 11:35 AM V8 (Infection Preventionist Nurse) and V11 (Certified Nursing Assistant
Supervisor/CNA) entered R25's room to provide incontinence care. V14 and V11 started to provide
incontinence care, and R25's incontinent brief was saturated with urine. They proceeded to turn R25
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146034
If continuation sheet
Page 4 of 12
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
02/09/2024
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 - Few
on her right side, and R25 had two incontinent cloth pads underneath her. The top pad was soiled with
urine.
On 2/08/2024 at 9:39 AM, V2 (Director of Nursing/DON) said nursing staff should change residents after
each incontinence episode to prevent infections and skin breakdown. V2 continued to say those residents
with urinary catheters should be provided catheter care if visible soiled after each incontinence episode. V2
said when nursing staff provide catheter care, they should use wipes to clean the catheter away from the
urethra, and when done, they should place the urinary catheter over the resident's leg below the bladder
and secure it with an anchoring device. V2 said failure to provide proper catheter care can also lead to
urinary tract infections.
The facility's Perineal Care policy with a review date of 5/21/2023, showed Intent: Perineal care is provided
to clean the perineum, prevent infection and odors, and provide comfort .Guideline: 1. Perineal care is done
daily and for all residents requiring assistance and/or those residents with a Foley catheter .4. Wash
perineal area and around catheter (if applicable) with Peri wash and water using a washcloth .7. Ensure
foley catheter is positioned correctly and secure. Wipe down tubing using downward stroke with clean cloth.
Support and secure tubing during procedure .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146034
If continuation sheet
Page 5 of 12
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
02/09/2024
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure emergency tracheostomy supplies
were available and failed to maintain sterile handling of a resident's sterile tracheostomy supplies. This
applies to 1 of 2 (R38) reviewed for tracheostomy care.
Residents Affected - Few
The findings include:
The EMR (Electronic Medical Record) showed R38 was admitted to the facility on [DATE] with diagnoses
including tracheostomy, acute and chronic respiratory failure with hypoxia, pneumonia, acute bronchitis,
chronic obstructive pulmonary disease with acute exacerbation, and history of COVID-19. The MDS
(Minimum Data Set) dated 1/16/2024 showed R38 was cognitively intact. The MDS continued to show R38
required respiratory treatments of continuous oxygen and tracheostomy care.
On 2/06/2024 at 10:22 AM, R38 was sitting up in her wheelchair in her room. R38 was receiving six liters of
oxygen therapy via her transtracheal catheter. R38 had a clear container box with opened sterile
transtracheal kits that contained transtracheal catheters and cleaning rods on top of her bedside table. The
box also contained other non-respiratory personal items. R38 also had an uncovered nebulizer mask
connected to a nebulizer machine on top of her nightstand table. R38 said she had her trach for a few years
and cares for it herself at the facility.
On 2/08/2024 at 9:18 AM, R38 was in bed and her bedside table still had the clear container box with
opened transtracheal sterile kits. There were trach cleaning rods mixed in with non-respiratory personal
items. R38 said she cleans her trach by squirting saline inside it and using the rod cleaner from her
transtracheal kit to get out mucous plugs. R38 said she changed her transtracheal catheter a week ago by
herself without any staff supervision. R38 said she used the transtracheal supplies she brought from home
and does not think the facility could provide them. R38 continued to say she was started on an antibiotic for
a lung infection.
On 2/08/2024 at 9:24 AM, V2 (Director of Nursing/DON) said she completed a resident and family
education with R38 regarding her transtracheal care on 2/07/2024 (during the survey). V2 said R38 takes a
normal saline bullet and squirts it inside and then clears any occlusions or mucous. V2 said facility staff
does not supervise R38 when performing her trach care. V2 said R38 was instructed to alert facility staff if
any concerns. V2 said to her knowledge, R38 does not change her own trach catheter. V2 continued to say
they provide R38 with saline and were not aware if R38 required other supplies for her trach care. V2 said
the respiratory therapist evaluates R38's respiratory care.
On 2/09/2024 at 8:56 AM, V2 said she was not aware R38 was exchanging her transtracheal catheter and
R38 does not have an order for the catheter exchange. V2 continued to say the facility does not have
transtracheal catheters or kits that R38 requires, and she was going to investigate what trach supplies R38
was using and how she was storing them in her room.
On 2/08/2024 at 9:24 AM, V15 (Respiratory Therapist) said R38 was totally independent with her trach care
because she has had the trach stoma for years. V15 said she tells R38 the process of flushing the trach.
V15 said she was aware of R38 keeping the sterile saline and transtracheal kits in a plastic container in her
room but has not looked at them recently. V15 said she thought the last time R38 exchanged her
transtracheal catheter was before her last discharge to home and was not aware she recently exchanged it.
V15 continued to say improperly stored respiratory equipment must be
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146034
If continuation sheet
Page 6 of 12
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
02/09/2024
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 0695
discarded, including sterile respiratory supplies.
Level of Harm - Minimal harm
or potential for actual harm
R38's EMR progress note dated 2/01/2024 at 7:02 AM, showed at 5:00 AM, R38 was complaining of
shortness of breath and her oxygen saturation dropped to 79% while receiving four liters of oxygen via her
transtracheal catheter. R38's progress note continued to show that R38 received an as needed breathing
nebulizer treatment and inhaler, and her oxygen was increased to six liters. R38's oxygen saturation
increased between 86-92%. The progress note continued to show the nurse notified the telehealth
physician and received orders to keep R38 on six liters of oxygen.
Residents Affected - Few
R38's EMR progress note dated 2/01/2024 at 9:07 AM, showed R38's physician was updated on R38's
status and ordered an immediate (STAT) chest x-ray and laboratory testing. R38's Radiology Results
Report dated 2/01/2024, showed R38 had early interstitial infiltrates in the right lung base. R38's EMR
progress note dated 2/01/2024 at 5:04 PM, showed R38's physician reviewed the chest x-ray results and
ordered R38 to continue with the antibiotic treatment.
R38's EMR respiratory note dated 2/02/2024 at 6:58 PM, showed a respiratory assessment was done and
a chart review which showed a new diagnosis of bronchitis. The respiratory note continued to show R38
was reiterated on breathing and cough techniques to help open her airway and no new recommendations.
R38's care plan dated 2/08/2024, showed a focus problem for tracheostomy and for R38 to perform trach
care and staff assist as needed. The care plan had multiple interventions including Oxygen (O2) @
4Liters/Minute per transtracheal tube .Transtracheal care-may irrigate as needed, irrigation may be
performed with either saline or sterile water to dislodge any mucus occlusion. The care plan did not show
any interventions for providing, storing, or maintain tracheostomy supplies, transtracheal catheter
exchange, or resident education process on maintain proper care of a transtracheal tracheostomy.
The facility's Transtracheal Catheter policy undated, showed Purpose: This policy outlines the guidelines
and procedures for the insertion, maintenance, and removal of transtracheal catheters to ensure patient
safety and quality of care. Scope: This policy applies to healthcare providers involved in the placement and
management of transtracheal catheters within the facility .Procedure: .3. Monitoring and Maintenance:
.-Educate patients on proper care, including cleaning and securing the catheter. 5. Staff Training: -Ensure
that healthcare providers involved in transtracheal catheterization are adequately trained and competent in
the procedure. 6. Equipment and Supplies -Maintain a sufficient supply of sterile equipment and ensure
proper function of oxygen delivery systems. 7. Documentation: -Thoroughly document all aspects of
transtracheal catheterizations, including patient assessment, procedure details, and follow-up care. The
facility's Care and Cleaning of Respiratory Equipment policy with a review date of 12/18/2023, showed
Equipment Change .Procedure: .IX. Tracheostomies A. Tracheostomy tubes will be changed every 90 days,
per physician order and per manufacturer recommendations .XII. Additional equipment .Respiratory tubing,
catheters, masks, cleaning kits will be secured or placed in a container, original package or bag. Facility
policies for tracheostomy care did not provide guidance on resident education on self-management of
transtracheal for residents with tracheostomy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146034
If continuation sheet
Page 7 of 12
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
02/09/2024
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 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to prevent the use of unnecessary antibiotic
medications. This applies to 1 of 4 residents (R25) reviewed for antibiotics in a sample of 23.
Residents Affected - Few
The findings included:
The EMR (Electronic Medical Record) showed R25 had diagnoses including recurrent urinary tract
infections (UTI), calculus of the kidney, and weakness. The MDS (Minimum Data Set) dated 12/16/2023
showed R25 was cognitively intact. The MDS showed R25 was receiving a high-risk drug of antibiotic.
R25's Order Summary Report dated 2/07/2024, showed an order for an antibiotic Macrodantin Oral
Capsule 50 MG (Nitrofurantoin Macrocrystal) to give 50 mg by mouth (PO) one time a day for recurrent UTI
with no stop date. R25's Care Plan dated 2/07/2024, showed R25 was receiving antibiotic therapy Macrobid
(Nitrofurantoin) related to recurrent UTIs for indefinite time, prophylactically. The care plan showed multiple
interventions, including reporting pertinent lab results to the physician.
R25's Medication Administration Record (MAR) for November 2023, showed R25 was started on Macrobid
(Nitrofurantoin) antibiotic on 11/30/2023 for urinary discomfort and UTI for seven days. R25's 11/29/2023
urinalysis laboratory results (reported 12/05/2023) showed the urine culture grew Citrobacter freundii
bacteria, which was sensitive to Nitrofurantoin, and Providencia rettgeri bacteria, which was resistant to
Nitrofurantoin.
R25's MAR for December 2023 showed R25 received Nitrofurantoin until 12/05/2023. The MAR showed
R25 received three doses of Invanz intravenous (IV) antibiotic starting on 12/7/2023 for the abnormal urine
culture. R25's 12/12/2023 urinalysis laboratory results (reported 12/16/2023) showed the sample did not
grow significant bacteria required for a culture.
R25's December MAR showed R25 was restarted on Nitrofurantoin 12/27/2023 for recurrent UTI, and
R25's January 2024 MAR showed R25 received Nitrofurantoin antibiotic until 1/31/2024 for recurrent UTI.
R25's 11/11/2024 laboratory urinalysis results (reported 1/15/2024) showed the urine culture grew Proteus
mirabilis and Providencia rettgeri bacteria, which were both resistant to Nitrofurantoin antibiotic.
R25's 2/5/2024 urinalysis laboratory results (reported 2/08/2024) showed the urine culture continued to
grow Proteus mirabilis bacteria and was resistant to Nitrofurantoin antibiotics. R25's MAR for February
2024, showed R25 continues to receive Nitrofurantoin antibiotic for recurrent UTI.
On 12/08/2024 at 9:35 AM, V2 (Director of Nursing/DON) and V8 (Infection Preventionist Nurse) said R25
was receiving a Macrobid antibiotic prophylactic because she was prone to getting UTIs. They said R25
was being treated by the Infectious Nurse Practitioner and they were aware R25 was now resistant to the
antibiotic Macrobid. They continued to say they did not agree with R25 antibiotic treatment.
On 12/08/2024 at 9:45 AM, V14 (Infectious Nurse Practitioner) said she was treating R25 for recurrent
UTIs. V14 said she uses urine culture results and allergies to determine which antibiotic to prescribe, but
with R25 it was difficult. V14 said R25 refused to take any other antibiotic except Macrobid. V14 said her
goal for treating R25 was to reduce her UTIs, and the treatment selected might not be ideal, but they are
working with what they have.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146034
If continuation sheet
Page 8 of 12
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
02/09/2024
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 0757
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
The facility document titled Infection Control ABT monitoring form dated 12/26/2023, showed R25 was
started on Macrobid for an indefinite time for recurrent UTI prophylaxis. The document continued to show
R25's antibiotic treatment did not meet the McGreers Criteria for antibiotic use and the physician was not
notified of the identified inappropriate use of the antibiotic.
The facility's Antibiotic Stewardship Review and Surveillance of Antibiotic Use and Outcomes policy with a
review date of 4/18/2023, showed Procedure: .2. The IP, or designee, will review antibiotic utilization as part
of the antibiotic stewardship program and identify specific situations that are not consistent with the
appropriate use of antibiotics. a. Therapy may require further review and possible changes if: 1. The
organism is not susceptible to antibiotic chosen; 2. The organism is susceptible to narrower spectrum
antibiotic; 3. Therapy was ordered for prolonged surgical prophylaxis; or 4. Therapy was started awaiting
culture, but culture results and clinical findings do not indicate continue need for antibiotics. 3. At the
conclusion of the review, the provider will be notified of the review findings
Event ID:
Facility ID:
146034
If continuation sheet
Page 9 of 12
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
02/09/2024
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
Based on observation, interview and record review, facility failed to contain, handle, and transport soiled
linen in a manner to prevent cross-contamination. This applies to 2 of 2 (R55 and R25) residents reviewed
for infection control in a sample size of 23.
Residents Affected - Few
Findings include:
1) On 2/6/24 at 11:15 AM, observed V7 (CNA-Certified Nursing Assistant) changing the bed linen for R55.
She threw the dirty linen on the floor, wiped down the bed, changed her gloves, and put fresh linen on the
bed. V7 picked up the loose soiled linen, unbagged, and carried it to the soiled linen room. V7 (CNA) stated,
that's what she always does and that she didn't know she had to bag the dirty linen before transporting it to
the soiled utility room.
On 2/7/24, observed V5 (CNA) in the hallway, holding unbagged soiled linen that was touching her body
and transported it to the dirty utility room. V5 (CNA) stated, she bags the soiled linen when resident is in
isolation, otherwise she just rolls it up and takes it to the soiled utility room. V5 (CNA) stated, this is how
they are taught in the in service. V5 (CNA) agreed that holding the soiled linen close to her body could
cause contamination / infection to herself and others.
On 2/7/24 at 9:42 AM, V6 (LPN) stated, Soiled linen should be bagged before bringing it out of the
resident's room and taken to the dirty utility room to avoid cross contamination.
On 2/8/24 at 10:43 AM, V2 (DON-Director of Nursing) stated, soiled linen should not be placed on the floor.
It must be put into a plastic bag and be bagged before transporting it to the soiled utility room.
3. The EMR (Electronic Medical Record) showed R25 had multiple diagnoses including recurrent urinary
tract infections, calculus of the kidney, and weakness. The MDS (Minimum Data Set) dated 12/16/2023
showed R25 had urinary and bowel incontinence. The MDS continued to show R25 was dependent on with
toileting hygiene and required substantial to maximal assistance with bed mobility from facility staff.
On 2/06/2024 at 12:55 PM, V10 (Certified Nurse Assistant/CNA) was leaving R25's room and walking down
the hallway towards the soiled utility room. V10 was holding a soiled incontinence cloth pad with an
ungloved hand and the pad was not bagged. V10 proceeded to enter the soiled utility room and dispose of
the soiled incontinence cloth pad. V10 said she performed incontinence care for R25 and had just disposed
of the R25's soiled incontinence cloth pad in the soiled utility room.
On 2/08/2024 at 9:39 AM, V2 (Director of Nursing/DON) said soiled items should be bagged and disposed
of accordingly, and soiled items should be handled with gloved hands for infection control.
The facility's Linen Management policy with a review date of 5/18/2023, showed It is the policy of the facility
to ensure linens are handled in a way to prevent cross contamination and the spread of infection in
accordance with State and Federal Regulations, and national guidelines. Procedure .6. Dirty linens are
contained in a closed container or bag. 7. Dirty linen are not to come in contact with staff clothing.
The facility's Handwashing/Hand Hygiene policy with a review dated 4/18/2023, showed This facility
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146034
If continuation sheet
Page 10 of 12
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
02/09/2024
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
considers hand hygiene the primary means to prevent the spread of infection .9. Single-use disposable
gloves should be used: Before aseptic procedure; When anticipating contact with blood or body fluid .
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146034
If continuation sheet
Page 11 of 12
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
02/09/2024
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 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to have functional call lights. This
applies to 2 of 3 residents (R8 and R266) reviewed for call lights in a sample of 23.
Residents Affected - Few
The findings include:
On 2/6/24 at 10:51 AM, R266 was in bed watching TV. R266 said he needed to be changed and asked
Surveyor to change him. Surveyor asked R266 to use his call light to call facility staff; R266's call light did
not light up outside R266's room. At 10:57 AM, Surveyor pushed R266's call light and it still did not light up
outside the room. At 11:00 AM, V12 (Restorative Aide) was walking down the hallway, Surveyor asked
which CNA (Certified Nurse Aide) was assigned to R266 and that the call light was not working, V12 was
not aware that R266's call light was not working. V12 said she would inform the CNA assigned and would
check on the call light. V10 (CNA) came in to R266's room and said she was not aware that the call light
was not working. V12 returned to R266's room, said Maintenance staff said there's a bell in the room for the
resident to use. V10 and V12 searched for the bell in R266's room and found it in the bedside drawer. V10
and V12 were not aware that the bell was in R266's room. R8 was R266's roommate and when Surveyor
pushed R8's call light, that call light did not work either. R8 had a call bell on his bedside table and the
bedside table was not within R8's reach.
On 2/7/24 at 9:53 AM, R266's and R8's call lights were still not working. R266 was sitting in his wheelchair
with the call bell on his bedside table, within reach. R266's call light was on the bed. R266 said he knew
how to use the call light but was not aware of why there was a call bell on his bedside table. R8 was in bed
resting at this time.
R266's MDS (Minimum Data Set) of 2/1/24 shows that R266's cognition was moderately impaired. R8's
MDS of 12/30/23 shows that R8's cognition was severely impaired.
On 2/7/24 at 3:41 PM, V1 (Administrator) said the call light should be in working condition and residents
should be educated on how to use the bell or alternate call system when the call light is down so residents
can notify staff when they need help.
The facility's Call Light Use policy (reviewed date 7/6/23) states the call system is utilized to alert staff of
resident's needs.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146034
If continuation sheet
Page 12 of 12
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Back to topCitations
7 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
FAQ · About this visit
Common questions about this visit
What happened during the February 9, 2024 survey of PEARL AT THE TILLERS?
This was a inspection survey of PEARL AT THE TILLERS on February 9, 2024. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PEARL AT THE TILLERS on February 9, 2024?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe and appropriate respiratory care for a resident when needed."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.