Health inspection·December 24, 2025

F 0694 Provide for the safe, appropriate administration of IV fluids 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 interview, and record review the facility failed to follow physician orders and facility policy for the care and maintenance of PICC (Peripherally Inserted Central Catheters) lines or Midline Intravenous access devices.This applies to 3 of 3 residents (R3, R6, R9) reviewed for intravenous medication administration in the sample of 9.Findings include:1. R6's EMR (Electronic Medical Record) showed R6 was admitted to the facility on [DATE], with multiple diagnoses including unspecified dementia, giant cell arteritis with polymyalgia rheumatica, chronic diastolic congestive heart failure, type 2 diabetes, chronic pain, and surgical wound right lower leg. Residents Affected - Few R6's MDS (Minimum Data Set) dated November 19, 2025, showed R6 was moderately cognitively impaired and required assistance with ADL care including set up assistance for eating and oral hygiene and was dependent on staff assistance for toileting, dressing, bathing, bed mobility and transfer. R6's physician order dated December 3, 2025, showed Non-Valved Midline, flush with 10 ml NS (Normal Saline) before and after med. There was an order for IV medication initiated on December 4, 2025, that showed cefazolin sodium Injection Solution Reconstituted 1 GM (Cefazolin Sodium) Use 1 gram intravenously every 8 hours for RLE shin wound abscess until December 16, 2025. There were no orders for the care and maintenance for the midline catheter, no order for dressing changes, nor measuring arm circumference or measuring external catheter length as required per facility policy. R6's physician order initiated on December 15, 2025, showed change PICC line dressing, measure circumference and length exposed and document in progress note every day shift every 7 day(s) for change PICC line dressing, measure circumference and length., start date December 16, 2025. There was no documentation to indicate if a new IV line had been placed or if this order was for the midline IV catheter already in use. R6's MAR (Medication Administration Record) for December 16, 2025, entry for the PICC line dressing change scheduled that day showed documentation of code 9. The legend on the MAR showed code 9 stood for other and to refer to the progress note. There was no progress note regarding R6's PICC line dressing had been changed and no documentation of arm circumference or external catheter length measurements. R6's MAR showed R6 had been administered IV medication from December 4 through December 21, 2025, with no indication that an IV insertion site dressing change had been done or monitoring IV catheter for potential migration or infiltration had been done. On December 23, 2025, V6 (RN) stated R6's midline catheter had been removed on December 22, 2025, and stated R6 had a midline and not a PICC line in use for IV medication administration. Page 1 of 3 146034 146034 12/24/2025 Pearl at the Tillers 4390 Route 71 Oswego, IL 60543

F 0694 R6's care plan did not address the care and maintenance of an IV or use of IV antibiotics. Level of Harm - Minimal harm or potential for actual harm 2. R3's EMR (Electronic Medical Record) showed R3 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis, cognitive of communicative disorders, Barrett's Esophagus dysplasia, acquired absence of left leg below the knee. R3 was transferred to the hospital on November 12, 2025, and had not returned to the facility. Residents Affected - Few R3's MDS (Minimum Data Set) dated November 10, 2025, showed R3 had moderately impaired cognition. R3's care plan showed R3 has a PICC line for IV antibiotic for infusion, interventions included assess for redness, tenderness, or swelling and to keep an eye on swelling, check the arm circumference against baseline, change dressing weekly or as needed. R3's hospital records showed R3 was admitted to the ER (Emergency Room) on November 12, 2025. V10 (Nurse) reported R3's PICC line dressing was dated October 31, 2025. On December 22, 2025, at 3:47 PM, request the facility to provide R3's physician order for PICC line care and required interventions. At 4:03 PM, V2 (DON) provided an order showing PICC line dressing change and measurement of arm circumference and length of exposed PICC line after PICC line dressing change done on admission and every 7days. V2 said when the order was entered, the category chosen was other and so it did not transfer onto the MAR (Medication Administration Record). V2 was not able to find any documentation that dressing had been changed or measurements taken of the arm circumference or exposed PICC line. 3. R9's EMR (Electronic Medical Record) showed R9 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis of vertebra lumbar region, infection and inflammatory reaction due to other internal joint prosthesis, Methicillin Resistant Staphylococcus Aureus site unspecified, acute osteomyelitis left ankle and foot, malignant neoplasm of larynx. R9's MDS (Minimum Data Set) dated November 16, 2025, showed R9 was cognitively intact. R9's care plan did not address the care and maintenance of his Midline catheter. R9's POS (Physician Order Set) showed an order to change PICC line dressing on admission and every 7 days and measure arm circumference and length of exposed PICC line. R9's MAR (Medication Administration Record) showed R9's dressing was changed on November 17, November 24, December 1, and December 8, 2025. R9's progress notes were reviewed and showed on November 17, 2025, the dressing change was completed, no signs/symptoms of infection, line patent and flushing appropriately, Length 16 cm and circumference 35 cm. On December 1, 2025, the dressing change was completed, no signs/symptoms of infection, line patent and flushing appropriately, Length 17 cm and circumference 35 cm. The facility was unable to provide progress notes showing the length of catheter or the arm circumference were measured when dressing was changed on November 24, or December 8, 2025. R9's Midline catheter was discontinued on December 10, 2025. On December 23, 2025, at 10:07 AM, R9 said he had an PICC line and staff changed the dressing a couple of times but was unsure if they measured his arm. 146034 Page 2 of 3 146034 12/24/2025 Pearl at the Tillers 4390 Route 71 Oswego, IL 60543

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On December 23, 2025, at 9:50 AM, V2 (DON/Director of Nursing) said when R3 came to us, he had an infection and was admitted here for IV (Intravenous). R3 was admitted with his PICC line in place. V2 further stated R3 had a PICC line and R9 had a Midline IV catheter. Facility provided their policy dated November 2022, and titled, Peripheral and Midline Intravenous Catheter Care and Dressing Changes showed, the dressing needs to be changed if loose, soiled, or damp and at least every 7 days with a transparent semi-permeable membrane dressing. If it is a midline catheter, the arm circumference needs to be measured and compared to baseline when indicated to assess for swelling and possible deep-vein thrombosis (blood clot). Facility provided their policy dated November 2022, and titled, Central Venous Catheter Care and Dressing Changes, showed, the dressing needs to be changed if loose, soiled, or damp and at least every 7 days for a transparent semi-permeable membrane dressing. The length of the external central vascular access device should be measured with each dressing change or if the catheter dislodgement is suspected and compared with the length documents at insertion. For PICC line, the arm circumference should be measured and compared to baseline when assessing for swelling and possible deep-vein thrombosis. 146034 Page 3 of 3