Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pearl At The Tillers during CMS and state inspections, most recent first.
A deficiency was identified when three dependent residents did not receive timely incontinence care or assistance with transfers as required by their care plans and the facility’s ADL policy. One resident with severe cognitive impairment and bowel incontinence was found in the morning with a large amount of stool leaked from the brief, a grossly soiled incontinence pad, and stool on the upper thighs after not being checked since early morning, despite a two‑hour check expectation. Another cognitively impaired, fully incontinent resident with impaired mobility was repeatedly found by family members lying in urine‑soaked briefs and clothing, with feces on bedding, and did not receive incontinence care for an extended period, even though the DON stated such residents should be checked at least every two hours. A third resident, dependent on a whole‑body mechanical lift for transfers, remained in bed over multiple observations and reported no one offered to get her up, while several CNAs acknowledged they had never gotten her out of bed and had not seen her up for months, and there was no documentation of any refusals or resisting‑care behaviors in the medical record.
The facility failed to follow physician orders and its own policies for the care and maintenance of PICC and Midline IV catheters for three residents receiving IV medications. This included missing or incomplete orders, lack of documentation for dressing changes and required measurements, and care plans that did not address IV care, resulting in inconsistent and undocumented catheter care.
A staff member failed to protect a resident's belongings when a CNA removed a resident's cell phone from the facility and disposed of it in a park trash can. The resident, who was cognitively intact and had multiple medical conditions, did not give permission for the phone to be taken. The incident was discovered after the family tracked the phone and retrieved it, and the CNA admitted to taking and discarding the phone.
The facility did not maintain sanitary conditions in the kitchen and during meal service, including improper sanitizer concentration, a malfunctioning dish machine that failed to reach required sanitation temperatures, uncovered meal carts with exposed food, and significant ice buildup in the walk-in freezer affecting stored prepared foods. Staff failed to follow established policies for sanitation and food storage.
Four residents on pureed diets did not receive pureed cornbread as required by the planned menu during a lunch meal. The Food Service Manager omitted the pureed cornbread during meal preparation and service, resulting in these residents not receiving the full nutritional components approved by the facility's dietitian.
Two residents did not receive proper catheter and perineal care, including failure to clean catheter tubing, improper positioning of the urinary drainage bag, and incomplete cleaning of the perineal area. These actions were inconsistent with facility policy and could contribute to urinary tract infections.
A resident with chronic trigeminal neuralgia repeatedly reported severe facial pain despite receiving scheduled and PRN pain medications. Nursing staff delayed reassessment and did not promptly notify the physician when pain remained uncontrolled, and documentation of pain management was incomplete. The care plan and facility policy requirements for pain assessment and intervention were not consistently followed.
CNAs did not adhere to infection control protocols by failing to change gloves and perform hand hygiene during and after providing incontinence and personal care to two residents. One CNA wore the same soiled gloves while performing multiple care tasks, and another handled soiled items without hand hygiene after glove removal, contrary to facility policy and DON instructions.
A resident with chronic respiratory failure was not provided with continuous oxygen as ordered due to a malfunctioning concentrator and lack of timely staff response. Despite repeated requests for assistance, the resident was without oxygen for over two hours until a family member intervened.
A CNA financially abused a resident by writing a $4000 check to herself from the resident's checkbook after discussing her financial hardships. The resident later reported the loss, and the facility's investigation confirmed the CNA's actions, leading to her termination. The facility's policies prohibit such actions, and the incident was documented in the complaint log.
Failure to Provide Timely Incontinence Care and Assistance With Transfers for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and assistance with transfers for residents who were dependent on staff for ADLs. One resident with Parkinson’s disease, polyarthritis, chronic pain, and a gastrostomy, and with severe cognitive impairment per the MDS, was care planned as bowel incontinent and dependent on staff for toileting hygiene. During morning care, a CNA found a large amount of pasty, formed stool that had leaked from the resident’s incontinence brief, with the incontinence cloth pad grossly soiled and saturated with brown stains across the mid and lower portions, and stool covering the back of the resident’s upper thighs. The CNA stated the resident was last checked around 5:30 AM, and the DON later confirmed that incontinent residents are to be checked every two hours for incontinence care, consistent with the facility’s ADL policy requiring assistance with hygiene for residents unable to perform ADLs independently. Another resident with multiple diagnoses including cerebrovascular disease, type 2 diabetes, chronic kidney disease, unspecified dementia with behavioral disturbances, CHF, and obstructive sleep apnea was documented as cognitively impaired, always incontinent of bowel and bladder, and dependent on staff for toileting hygiene. The care plan identified impaired mobility, decreased self-bed mobility, and a need for assistance with toileting. Two family members reported finding this resident on multiple occasions lying in a soiled, urine‑soaked incontinence brief full of feces and in uncomfortable positions, and one family member reported being present from early morning until late morning before a CNA entered to provide a diaper change. The family member also reported seeing feces on the blanket, which a CNA removed and placed on a chair. The assigned CNA stated she checked the resident at the start of her shift and again two hours later and found the resident dry, and that she next checked the resident at 11:00 AM, when she observed stool and brown substances on the blanket. The staffing coordinator confirmed assisting with incontinence care at 11:00 AM, and the DON stated incontinent residents should be checked at least every two hours and that this resident should have received incontinence care sooner than over two hours when wet or saturated. A third resident with diagnoses including cerebral infarction, type 2 diabetes, abnormal posture, acute pulmonary edema, urinary retention, anxiety, and hypertension was documented on the MDS as dependent on staff for transfers. This resident reported that staff did not want her to sit in a wheelchair because they thought she would fall, and that she would like to get up in the wheelchair and had not been out of bed for a long time. On multiple observations over two consecutive days, the resident was seen lying in bed, and she stated no one had offered to get her out of bed and that she would have liked to get up and wheel down the hallway. Several CNAs confirmed that the resident required a whole‑body mechanical lift, that it was part of their routine to get residents up in the morning and to document refusals, but each stated they had never gotten this resident out of bed and had not seen her up in a chair for months. One CNA admitted she did not ask the resident if she wanted to get out of bed when she got the roommate up with a mechanical lift, despite knowing she should have asked. Review of progress notes, point‑of‑care tasks, and the EMAR over approximately one month showed no documentation of the resident refusing to transfer out of bed or exhibiting resisting‑care behaviors, despite the DON’s expectation that refusals be charted, and the facility’s ADL policy requiring appropriate support and assistance with mobility, including transfers.
Failure to Follow Physician Orders and Policy for IV Catheter Care and Maintenance
Penalty
Summary
The facility failed to follow physician orders and its own policies regarding the care and maintenance of PICC lines and Midline intravenous access devices for three residents who required IV medication administration. For one resident with multiple diagnoses including dementia, heart failure, diabetes, and a surgical wound, there were no physician orders for midline catheter care, dressing changes, or required measurements, and no documentation that these interventions were performed during the period IV medications were administered. The resident's care plan also did not address IV care or antibiotic use. Another resident, admitted with a PICC line for IV antibiotics and cognitive impairment, had a care plan that included specific interventions such as assessing for redness, swelling, and changing the dressing weekly. However, documentation showed the PICC line dressing had not been changed for nearly two weeks prior to hospital transfer, and there was no evidence that required measurements or dressing changes were performed or documented. The facility's DON confirmed that the physician order for PICC line care was entered in a way that did not transfer to the MAR, and no documentation could be found for the required interventions. A third resident with a Midline catheter and multiple infections had a care plan that did not address catheter care. While some dressing changes and measurements were documented, there were gaps in documentation for required measurements during dressing changes. Facility policy required dressing changes at least every 7 days and measurement of arm circumference and catheter length, but these were not consistently documented or performed as required.
Staff Member Removed and Disposed of Resident's Personal Property
Penalty
Summary
A staff member failed to protect a resident's personal property when a certified nursing assistant (CNA) removed a resident's cellular telephone from the facility and later disposed of it in a trash receptacle at a local park. The incident was discovered after the resident's family, using a phone tracking application, determined that the phone had left the facility and was located in a park trash can. The family retrieved the phone and returned it to the resident. The CNA admitted to taking the phone, stating she was overwhelmed and accidentally picked it up, but then panicked and discarded it instead of returning it to the facility. The resident involved was cognitively intact and had multiple medical diagnoses, including non-rheumatic aortic valve stenosis, difficulty walking, COPD, asthma, diabetes, morbid obesity, atrial fibrillation, congestive heart failure, heart disease, lymphedema, and osteoarthritis. The resident required varying levels of assistance with activities of daily living and was occasionally incontinent of urine and frequently incontinent of stool. The resident reported that the phone was left on the bedside table before going to lunch, and upon return, it was missing. The resident did not give anyone permission to use or remove the phone. Facility documentation and interviews confirmed that the CNA took the phone, realized it was not hers after leaving the facility, and disposed of it in a public trash can. The facility's abuse prevention policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings without consent. The local police were notified, and the CNA admitted to the actions during the investigation.
Failure to Maintain Sanitary Food Service and Storage Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and during meal service, affecting 58 residents who received food prepared in the facility kitchen. During an initial kitchen tour, a sanitizer bucket was found to have 0 ppm of quaternary ammonium when tested, indicating it was not effective for sanitizing. The Food Service Manager confirmed that the new cook had just filled the bucket, but the sanitizer concentration was not within the required range. Additionally, the dish machine, which is a high-temperature unit, showed a rinse temperature of only 130°F on the gauge instead of the required 180°F. The Food Service Manager acknowledged the gauge was not working and that the piping connection at the base of the machine was loose, an issue that had been reported a week prior. When tested with a temperature-sensitive strip, the dish machine failed to reach the required sanitation temperature, and dishes washed in the machine could not be verified as sanitized. Review of dish machine logs for the previous week showed that temperatures were recorded as 160/180°F, but the dietary aide responsible for the logs admitted to only looking at the gauge and not using the test strip, assuming the machine was functioning correctly. During meal service, two uncovered meal carts with open desserts were observed parked near the nursing station, exposed to staff and visitors passing by. The Food Service Manager stated that dietary staff are responsible for covering meal carts before delivery, but this was not done. Further inspection of the facility's walk-in freezer revealed significant ice buildup over prepared foods stored in pans covered with foil, with some foil broken and ice seeping onto the food. The freezer contained foods prepared as far back as December and January, and the Food Service Manager attributed the ice buildup to recent weather fluctuations. Facility policies required cleaning cloths to be kept in sanitized solution, dish machine temperatures to be logged after each meal, and freezers to be defrosted monthly or as needed, but these procedures were not followed as observed.
Failure to Serve Pureed Cornbread as Planned for Residents on Pureed Diets
Penalty
Summary
The facility failed to provide pureed cornbread as specified on the planned menu to residents on pureed diets. On March 3, 2025, during the preparation and service of the lunch meal, the Food Service Manager prepared and served pureed Country Chicken and Dumplings and Glazed Carrots, but did not puree or serve the cornbread portion to residents requiring pureed diets. Instead, residents received pureed chicken and dumplings, glazed carrots, and applesauce (upon request), but did not receive the pureed cornbread as indicated on the menu extension sheet and required by their dietary orders. This deficiency affected four residents who were on pureed diets, as confirmed by the facility's resident diet order listing. The facility's dietitian confirmed that the menu had been reviewed and approved to meet daily nutritional requirements, and that the pureed cornbread was necessary to provide the bread serving for the meal. The omission of the pureed cornbread meant that the planned menu was not followed and the nutritional adequacy for these residents was not met as intended.
Failure to Provide Proper Catheter and Perineal Care to Prevent UTIs
Penalty
Summary
The facility failed to provide appropriate urinary catheter and perineal care to two residents, resulting in practices that could contribute to urinary tract infections (UTIs). One resident with an indwelling catheter due to obstructive uropathy was found lying in a urine-soaked bed, reporting not having been changed all day. During perineal care, the CNA cleaned the resident's peri-area but neglected to clean the catheter tubing, and the catheter anchor was nearly detached, eventually coming off completely. The urinary drainage bag was repeatedly lifted above the bladder level, causing urine with sediment to backflow toward the bladder. The resident's incontinence brief was saturated with dark brown, strong-smelling urine, and the CNA admitted to not checking the resident for dryness since the start of her shift. Another resident requiring incontinence care was found wet with urine and a bowel movement. During care, the CNA cleaned only the outer labial area and back peri-area, omitting the abdominal folds, inner groin, and labial folds. According to the facility's Director of Nursing and written policy, proper perineal care should include cleaning all these areas and, for residents with catheters, cleaning the catheter tubing away from the body and ensuring the tubing is secured and positioned below the bladder. These lapses in care were directly observed and confirmed by staff interviews and policy review.
Failure to Adequately Assess and Manage Chronic Pain
Penalty
Summary
A deficiency occurred when the facility failed to adequately evaluate and manage a resident's chronic pain associated with trigeminal neuralgia. The resident, who was cognitively intact, repeatedly reported severe pain in her right cheek, rating it as 8 to 10 out of 10, despite having received her prescribed pain medications, including Gabapentin and Tramadol. Observations showed that Gabapentin was administered late, and the resident continued to experience significant pain after receiving both Gabapentin and Tramadol. The resident also stated that Tylenol was ineffective for her nerve pain, yet it continued to be offered as an intervention. Nursing staff did not promptly reassess the resident's pain after administration of PRN pain medication, nor did they notify the physician in a timely manner when the resident's pain remained uncontrolled. Documentation of pain assessments and the effectiveness of administered medications was incomplete, and non-pharmacological interventions were either not offered or declined by the resident. The care plan indicated the need to monitor for pain and assess the effectiveness of interventions, but these steps were not consistently followed. The facility's pain management policy required staff to assess pain, monitor for behavioral signs, and notify the practitioner if pain was not controlled by the current regimen. Despite these requirements, staff delayed contacting the physician for further orders when the resident's pain persisted at the highest level, and did not revise the pain management plan until after repeated complaints and observations of severe pain.
Failure to Follow Hand Hygiene and Gloving Protocols During ADL Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow standard infection control practices during the provision of activities of daily living (ADL) care for two residents. In one instance, a CNA performed perineal care, changed an incontinence brief, repositioned the resident, and adjusted pillows and clothing while wearing the same soiled gloves throughout the process. This action did not comply with the facility's hand hygiene policy, which requires hand hygiene and glove changes when moving from a contaminated body site to a clean body site and after removing gloves. In another instance, two CNAs provided incontinence care to a resident who was wet with urine and bowel movement, assisted with washing and dressing, and then one CNA removed her gloves and handled soiled items without performing hand hygiene before leaving the resident's room. The Director of Nursing confirmed that staff are required to perform hand hygiene and change gloves before starting care, when moving from dirty to clean tasks, after care, and before leaving the resident's bedroom to prevent the spread of infection.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to follow a physician's order for oxygen administration for a resident with chronic respiratory failure and other significant health conditions. The resident, who was alert and oriented, was admitted with a physician's order to receive continuous oxygen at 2 liters for hypoxemia. However, upon admission, the oxygen concentrator provided was not functioning properly, leading to the resident being placed on a portable oxygen tank, which subsequently ran out of oxygen. Despite the resident's and a CNA's repeated requests for assistance, the assigned nurse did not respond in a timely manner, resulting in the resident being without oxygen for over two hours. The resident eventually had to call a family member to assist with setting up a new oxygen concentrator. The CNA confirmed the resident's account, stating that she informed both the registered nurse and the nursing manager about the oxygen issue, but neither attended to the resident's needs. The Director of Nursing later stated that staff are expected to follow physician's orders, indicating a lapse in protocol adherence by the nursing staff involved.
Resident Financial Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from financial abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The CNA, identified as V8, was providing care to the resident, R1, and during their interaction, V8 discussed her financial hardships. R1 mentioned the word 'check,' which led V8 to provide R1 with her checkbook. V8 then wrote a check to herself for $4000, which R1 signed, allegedly stating she wanted to help. V8 deposited the check into her account the same day. R1 later reported the loss of $4000 and $21 in cash, stating that V8 had taken the check from her purse and written it to herself. The facility's investigation revealed that V8 had indeed taken the check from R1, leading to V8's immediate termination. The facility's employee handbook prohibits the acceptance of gifts from residents, and the facility's Abuse Prevention Program defines misappropriation of resident property as the wrongful use of a resident's belongings or money without consent. The incident was documented in the facility's complaint log, and R1's daughter was alerted to the theft by the bank, which contacted her regarding the suspicious transaction.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oswego
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jennings Terrace | 5.2 mi | ★★★★★ | 0 | 0 |
| Hillside Rehab & Care Center | 5.6 mi | ★★★★★ | 9 | 0 |
| Alden Courts Of Waterford | 5.6 mi | ★★★★★ | 12 | 1 |
| Alden Of Waterford | 5.7 mi | ★★★★★ | 5 | 0 |
| La Bella Of Aurora | 5.8 mi | ★★★★★ | 3 | 0 |
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