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Complaint Investigation

Pearl Of Joliet, The

October 17, 2025 · Joliet, IL · 306 North Larkin Avenue
Citations 2
CMS Rating 1/5
Beds 214
Provider ID 145372
Healthcare Facility
Pearl Of Joliet, The
Joliet, IL  ·  View full profile →
Inspection Summary

PEARL OF JOLIET, THE in JOLIET, IL — inspection on October 17, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0693
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

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 R1 reviewed for their tube feeding in a sample of 8.Findings include:On 10/15/25 at 10:33 AM, R1 was observed during care provision by V9 and V10, CNAs (Certified Nursing Assistants).

While 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 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 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.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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Pearl of Joliet, The

306 North Larkin Avenue Joliet, IL 60435

SUMMARY STATEMENT OF DEFICIENCIES

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 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.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 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 R1 received the Meropenem 500 MG on 9/14/25. V2 stated she did not receive any authorization requests from pharmacy for R1 to receive the one-time dose of Levofloxacin 750 MG. V2, DON, stated there was no documentation showing 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.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in JOLIET, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PEARL OF JOLIET, THE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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