Pearl at the Tillers

In the surveyor’s words

From the most serious findings on record at Pearl at the Tillers, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 10, 2021

  Based on observation, interview and record review, the facility failed to ensure a resident identified as an elopement risk was provided adequate supervision to prevent elopement from the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on May 25, 2021 when R1 eloped from the facility without being witnessed by facility staff. This applies to 1 of 4 residents (R1) identified by the facility as high risk for elopement in the sample of 8. V1 (Administrator), V2 (DON-Director of Nursing), and V12 (Regional Nurse Consultant) were notified of the Immediate Jeopardy on June 3, 2021 at 11:55 AM. […]

• No harm, potential for more than minimal, widespreadF812Mar 6, 2025

  Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the facility kitchen and during meal service. This applies to 58 residents that received foods prepared in the facility kitchen. Findings include: The facility's Long Term Care Facility Application for Medicare and Medicaid dated March 3, 2025 showed the facility census was 59 residents. The facility provided information that there was one resident on NPO (nothing by mouth) status. […]

• No harm, potential for more than minimal, widespreadF812Jan 12, 2023

  Based on observation, interview, and record review the facility failed to serve food in a sanitary manner to prevent cross contamination. This applies to all 70 residents that consume meals orally. The Findings include: The facility census list of January 9, 2023, documents 71 residents in the facility. V2 (Director of Nursing/DON) stated during an interview of January 12, 2023, at 3:55PM that only one resident is NPO (Nothing Per Oral) in the facility. On January 9, 2023, at 12:09 PM, V16 (Cook) was observed preparing and plating food from the steam table. The menu was Tuscan chicken breast, spaghetti noodles, mixed vegetables, garlic toast. V16 was observed using tongs for the spaghetti noodles and then using his gloved hand to place noodles on the plate. […]

• No harm, potential for more than minimal, widespreadF868Jun 10, 2021

  Based on interview and record review the facility failed to conduct quarterly QA (Quality Assurance) meetings and failed to ensure V23 (Medical Director) attended QA meetings or was updated regarding meeting minutes or concerns identified. This applies to all 59 residents residing at the facility. The findings include: The Facility Data Sheet dated June 1, 2021 shows the facility census as 59 residents. V1 (Administrator) was asked to provide attendance sign in sheets for all QA Committee meetings for the period June 1, 2020 to June 1, 2021. The facility could not provide QA meeting attendance sheets to show quarterly QA meetings had taken place for the same period. V1 provided meeting minutes entitled Compliance Committee Meeting Minutes dated December 2020, January 2021, and April 2021. […]

• No harm, potential for more than minimal, patternF803Mar 6, 2025

  Based on observation, interview, and record review, the facility failed to provide pureed corn bread as per planned menu to residents on pureed diets. This applies to 4 of 4 residents (R7, R15, R24, R273) reviewed for pureed diets in the sample of 16. Findings include: Facility Week at a Glance menu showed that the lunch meal for March 3, 2025 included Country Chicken and Dumplings, Glazed Carrots, Cornbread and Diced Pears. Facility Menu Extension sheet for pureed consistency included 2 #8 scoops of Country Chicken and Dumplings, #8 scoop of Glazed Carrots, #16 scoop of Cornbread, and #8 scoop of Diced Pears. Facility Dipper/Ladle Equivalents chart showed that #8= 4 fluid oz/ounce, #16 =2 fluid oz. […]