Pearl Of Joliet, The

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Based on observation, interview, and record review, the facility failed to maintain the head of bed at thirty degrees while a resident's tube feeding was infusing. This applies to 1 of 4 residents Resident R1 reviewed for their tube feeding in a sample of 8.Findings include:On 10/15/25 at 10:33 AM, Resident R1 was observed during care provision by V9 and V10, CNAs (Certified Nursing Assistants). While Resident R1 was in bed, the head of the bed was in a flat position. The tube feeding of Nepro 1.8 Cal was infusing at 40 ML (Milliliters) per hour by a feeding pump. V10 CNA stated residents receiving their tube feedings only needed to have the head of bed elevated if the resident is being rolled side to side, otherwise it is ok for the resident to be flat with the tube feeding infusing.V9 CNA stated there was no problem with Resident R1's head of bed being flat while her tube feeding was infusing if she was not being turned side to side as it may cause Resident R1 to become sick.On 10/15/25 at 5:15 PM, V2, DON (Director of Nursing), stated the head of bed should be elevated when the tube feeding is infusing so that the resident does not vomit or aspirate.Resident R1's physician orders tube feeding states may stop feeding during routine care, ADL's (Activities of Daily Living), bathing, notify nurse to restart. Every shift elevates head of bed 30 -45 degrees while feeding.The facility policy Tube Feeding, dated 11/2024, states the head of bed will be 30-45 degrees unless ordered differently.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Joliet, The

306 North Larkin Avenue Joliet, IL 60435

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 interview and record review, the facility failed to administer the ordered initial dose of an antibiotic. This applies to 1 of 4 residents Resident R1 reviewed for antibiotic administration in a sample of 8.Findings include:V5, NP (Nurse Practitioner) progress note on 9/12/25 documents the plan for to treat a UTI (Urinary Tract Infection) with Levofloxacin IV (Intravenously). Levofloxacin 750 MG (Milligrams) to start on 9/13/25 and end 9/14/25. Levofloxacin 500 MG administered every 48 hours for 10 days starting 0 9/15/25 and ending on 9/25/25. Meropenem 500 MG intravenously daily for 7 days starting on 9/9/25.Resident R1's MAR (Medication Administration Record) shows a missed administration of Meropenem 500 MG on 9/14/25 at 9am. There is no documentation for the administration of Levofloxacin 750 MG on Resident R1's MAR on 9/13/25 or 9/14/25. V4, LPN (Licensed Practical Nurse) progress, note dated 9/14/25 at 3:25 AM, states call to pharmacy related to Levofloxacin would be delivered early in AM. A nursing progress note, dated 9/14/25 at 6:42 PM, states Levofloxacin 750 MG was not available and would be delivered that night. Calls placed to

interview V5, NP, and V4, LPN, were unsuccessful.V2, DON (Director of Nursing), stated there was no documentation showing Resident R1 received the Meropenem 500 MG on 9/14/25. V2 stated she did not receive any authorization requests from pharmacy for Resident R1 to receive the one-time dose of Levofloxacin 750 MG. V2, DON, stated there was no documentation showing Resident R1 received the one-time dose of Levofloxacin 750 MG.The facility policy Medication Ordering and Receiving from Pharmacy, dated November 2021, states a licensed nurse promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse / supervisor.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet