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 Aperion Care Fox River during CMS and state inspections, most recent first.
The facility failed to implement adequate infection control measures, including monitoring for Legionella and adhering to Enhanced Barrier Precautions (EBP) and hand hygiene policies. The Maintenance Director did not test for chlorine levels, relying on outdated city reports. A nurse failed to follow EBP and hand hygiene protocols during medication administration for a resident with a tracheostomy and feeding tube, affecting all 81 residents.
A resident with a history of falls and multiple diagnoses, including a right hip fracture and dementia, did not have a floor mat placed beside her bed as required by her care plan. Despite being moved closer to the nursing station and having a bed alarm, the absence of the floor mat was confirmed by both an LPN and a Restorative Nurse, violating the facility's Fall Prevention Program.
A resident with multiple diagnoses, including dementia and pressure ulcers, experienced tube feeding intolerance and inadequate fluid intake. Despite adjustments to the feeding regimen, the resident's nutritional and fluid needs were not met, leading to signs of dehydration. The facility's policy on enteral nutrition was not adequately followed, and alternative feeding methods were not considered due to the resident's hospice status.
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting all residents receiving oral nutrition. Expired food items, including beef liver, pumpkin pulp, slivered almonds, shredded cheese, and leftover meat, were found during a kitchen tour. The Dietary Manager and Cook confirmed these items were expired and should have been discarded.
The facility failed to properly assess and assist dependent residents with transferring and positioning, leading to multiple deficiencies. Residents were observed in uncomfortable and unsafe positions in their wheelchairs, and staff used improper methods for transfers and repositioning, causing discomfort and potential injury. The facility's policies and procedures for using mechanical lifts and ensuring safe transfers and positioning were not adequately followed.
The facility failed to provide appropriately sized wheelchairs and necessary assistive devices for two residents, leading to significant discomfort and difficulty in daily activities. One resident experienced pain and frustration due to an ill-fitting wheelchair and low toilet seat, while another resident was observed leaning uncomfortably in a too-wide wheelchair lacking a cushion and footrest.
The facility failed to assist two residents with eating during meal service. One resident, with severe cognitive impairment and multiple diagnoses, was observed eating with fingers and not receiving necessary assistance. Another resident, with severe cognitive impairment and physical limitations, struggled to eat independently without the required supervision or assistance from staff.
The facility failed to evaluate and treat residents with skin conditions and ensure proper functioning and awareness of a resident's pacemaker transmitter. One resident had untreated skin issues, another had undocumented papules, and a third had a non-functioning pacemaker transmitter with staff unaware of its importance.
The facility failed to ensure timely changes of an indwelling urinary catheter drainage bag and tubing for a resident, despite visible sediments and an order to change as needed. Documentation in the Treatment Administration Record and progress notes was lacking, leading to the deficiency.
The facility failed to provide appropriate respiratory care for two residents. One resident used an empty oxygen cylinder for over an hour, and another resident's CPAP mask was repeatedly found lying on the bed or floor and not contained in a bag. The facility could not provide a policy for oxygen use.
Inadequate Infection Control Measures and Policy Adherence
Penalty
Summary
The facility failed to develop adequate control measures for internal factors that increase the risk of Legionella growth and did not have intervention strategies when control measures were not met. The Maintenance Director, V6, reported that the facility's water management plan included weekly faucet flushes, periodic eye wash station flushes, daily hot water tank temperature checks, and bi-weekly ice machine cleaning. However, the facility did not test for chlorine levels in the water, relying instead on the city's water report from 2023. The Administrator, V1, confirmed that the facility does not regularly test for Legionella unless there is a suspected case and corporate approval is given. The Vice President of Operations, V8, also acknowledged the lack of control measures to monitor disinfectant levels in the facility's water. The facility also failed to adhere to its Enhanced Barrier Precautions (EBP) and hand hygiene policies. Resident R179, who had a tracheostomy and Jejunostomy feeding tube, required EBP. However, during a medication administration observation, the Registered Nurse, V3, did not perform hand hygiene or don a gown before entering R179's room. V3 also failed to perform hand hygiene after leaving the room and touching various surfaces, including a garbage can, before preparing medications for another resident, R40. The Director of Nursing, V2, stated that EBP requires staff to wear gloves, gowns, and masks if necessary, and to perform hand hygiene before and after entering rooms with residents on EBP. The facility's policies on hand hygiene and Enhanced Barrier Precautions were not followed, as evidenced by the actions of V3 during medication administration. The facility's Hand Hygiene/Handwashing policy requires hand hygiene at room entry, before exiting, after contact with inanimate objects, and after glove removal. The Enhanced Barrier Precautions policy mandates the use of PPE during high-contact resident care activities. These deficiencies in infection prevention and control measures were observed to affect all 81 residents residing in the facility.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident with a history of falls, leading to a deficiency in ensuring a safe environment free from accident hazards. The resident, identified as R68, had a care plan revised in February 2024, which included diagnoses such as right hip fracture, history of falls, dementia, osteoarthritis, and osteopenia. The care plan indicated that R68 was at risk for falls due to impaired cognition and mobility, requiring assistance with ADLs. Interventions to prevent further falls included the use of a low bed, a floor mat next to the bed, and a bed mobility alarm. Additionally, R68 was moved to a room closer to the nursing station for better supervision. Despite these interventions, observations on March 10 and 11, 2025, revealed that the floor mat was not placed beside R68's bed while she was asleep, although the bed was in a low position and the bed alarm was in place. Both a Licensed Practical Nurse (V4) and a Restorative Nurse (V5) confirmed that the floor mat was supposed to be in place as part of the fall prevention measures. The facility's Fall Prevention Program, dated November 2012, mandates the implementation of safety interventions for residents identified at risk, which was not adhered to in this case, resulting in the deficiency.
Failure to Address Tube Feeding Intolerance and Fluid Needs
Penalty
Summary
The facility failed to adequately address the nutritional and fluid needs of a resident dependent on enteral feeding, leading to a deficiency in care. The resident, who was admitted with multiple diagnoses including Wernicke's encephalopathy, dementia, and pressure ulcers, was on a tube feeding regimen of Jevity 1.2 with specific water flush orders. Despite initial assessments and recommendations by the dietitian, the resident experienced issues with tube feeding intolerance, such as bloating and high residuals, which were not effectively managed. The resident's feeding regimen was adjusted multiple times due to intolerance, but the adjustments did not meet the resident's nutritional and fluid needs. The dietitian noted that the resident was receiving insufficient calories and fluids, which could lead to dehydration and other complications. The resident's intake and output records showed inadequate fluid intake, and observations by the RN indicated signs of dehydration, such as dark amber urine. Despite these observations, alternative feeding methods, such as continuous feeding, were not considered due to the resident's hospice status. The facility's policy on enteral nutrition emphasized the importance of monitoring and adjusting feeding regimens to meet individual needs, but this was not adequately followed. The dietitian and nursing staff did not collaborate effectively to explore alternative feeding strategies or consult with the hospice nurse, resulting in the resident's nutritional needs not being met. This lack of coordination and adherence to policy contributed to the deficiency in care for the resident.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting all residents receiving oral nutrition. During a tour of the facility kitchen, several expired food items were found, including two boxes of beef liver in the walk-in freezer, a can of pumpkin pulp, a bag of slivered almonds in the dry storage room, and various opened bags of shredded cheese and leftover meat in the kitchen cooler. The Dietary Manager and Cook confirmed that these items were expired and should have been discarded to prevent potential health risks to residents. The Director of Nursing confirmed that all residents receive food from the facility kitchen, and the Dietician emphasized the risk of food poisoning from expired food. The facility's policy on food storage, last revised in 2020, mandates the disposal of expired food items. Despite this policy, the expired items were not discarded, posing a potential health risk to the residents.
Improper Assessment and Assistance with Transfers and Positioning
Penalty
Summary
The facility failed to properly assess and assist dependent residents with transferring and positioning, leading to multiple deficiencies. Resident R41, who had multiple diagnoses including hemiplegia and severe cognitive impairment, was observed in an uncomfortable and unsafe position in her wheelchair. Despite her inability to use the mechanical sit-to-stand lift due to her right hand not functioning, staff used the device, causing her pain and requiring additional physical support. The resident's care plan indicated she was at risk for injuries and required proper assessment and interventions, which were not adequately followed by the staff. Resident R49, who had severe cognitive impairment and required substantial assistance for transfers, was also improperly assisted. He was observed in an uncomfortable position in his wheelchair, with his cushion not properly placed and his legs awkwardly positioned. Staff used the mechanical sit-to-stand lift without securing the shin support strap, causing the resident discomfort and frustration. Additionally, staff attempted to reposition him by pulling underneath his armpits and gripping his pants, which is against proper procedure and could cause injury. Residents R275 and R57, both severely cognitively impaired and dependent on staff for mobility, were observed in slouched and unsafe positions in their wheelchairs. Staff failed to ensure proper positioning and used inappropriate methods to reposition them, such as pulling on their pants. The facility's policies and procedures for using mechanical lifts and ensuring safe transfers and positioning were not adequately followed, leading to these deficiencies.
Failure to Provide Properly Sized Wheelchairs and Assistive Devices
Penalty
Summary
The facility failed to provide appropriately sized wheelchairs and necessary assistive devices for two residents, leading to discomfort and difficulty in daily activities. One resident, who was 76 inches tall and weighed 147 pounds, was observed sitting uncomfortably in a wheelchair that was too small, with his legs awkwardly positioned and his feet falling off the footrests. Additionally, this resident experienced discomfort during toileting transfers due to the toilet seat being too low for his height. The resident expressed frustration and pain during these activities, indicating a significant deficiency in accommodating his needs. Another resident, who was 62 inches tall and weighed 91 pounds, was observed in a high-back wheelchair that was too wide, causing her to lean uncomfortably to one side. This resident's wheelchair also lacked a cushion and had only one footrest attached, further contributing to her discomfort. The Physical Therapy Director acknowledged that both residents would benefit from different wheelchair models and additional assistive devices to ensure proper positioning and comfort. The facility's failure to provide these necessary accommodations highlights a deficiency in meeting the residents' needs and preferences.
Failure to Assist Residents with Eating
Penalty
Summary
The facility failed to assist residents needing help with eating during meal service, specifically affecting two residents. Resident R44, diagnosed with hypertensive heart disease, dementia, Alzheimer's Disease, gastro-esophageal reflux disease, and diabetes, was observed eating with fingers despite being dependent on staff for eating. The care plan indicated that R44 required extensive assistance with eating, but staff did not offer reminders or assistance during meal times. Observations showed R44 eating with fingers, wiping hands on clothing, and having food particles on the front of the shirt and pants. Staff members present did not intervene or provide the necessary assistance as outlined in the care plan. Resident R40, diagnosed with sequelae of cerebral infarction, dysphagia, right hemiplegia and hemiparesis, aphasia, and vascular dementia, was observed struggling to eat independently. Despite needing supervision or touching assistance during meals, R40 was seen eating with difficulty, spilling food, and using inappropriate methods to consume food, such as scooping with the tongue and licking the bowl. Staff did not provide the required supervision or assistance during these observations, and R40's silverware remained unused. Interviews with staff confirmed that R40 needed supervision and occasional assistance, but this was not provided during the observed meal times.
Failure to Evaluate and Treat Skin Conditions and Ensure Pacemaker Transmitter Function
Penalty
Summary
The facility failed to evaluate and treat residents with skin conditions and ensure proper functioning and awareness of a resident's pacemaker transmitter. Resident R44, who had severe cognitive impairment and multiple diagnoses, was observed with scattered red marks, open areas, and scabbed areas on her arms, back, and other parts of her body. Despite having orders for skin checks and treatment, the staff failed to document and address these skin conditions adequately. CNAs and nurses were unaware of the extent of R44's skin issues, and the documentation did not reflect the actual condition of the resident's skin. Resident R5, who had moderate cognitive impairment, was observed with maroon-red papules on her right foot and calf. Despite R5 notifying the nursing staff about these papules, there was no documentation or assessment of the condition in the progress notes or care plan. The CNAs and nurses were unaware of R5's skin condition, indicating a lack of proper skin assessments and communication among the staff. Resident R35, who had a cardiac pacemaker, was found to have a non-functioning pacemaker transmitter at his bedside. The staff, including CNAs and nurses, were unaware of the resident's pacemaker and the need for the transmitter to be plugged in and functioning. The transmitter had been unplugged for an extended period, and the cardiology clinic had lost contact with the device. This lack of awareness and proper functioning of the transmitter could have led to missed notifications of adverse cardiac events.
Failure to Timely Change Urinary Catheter Drainage Bag and Tubing
Penalty
Summary
The facility failed to ensure timely changes of an indwelling urinary catheter drainage bag and tubing for a resident. On two separate observations, the resident's catheter drainage bag tubing was noted to have a large amount of sediments and was white in color. Despite having an order to change the tubing and bag as needed when visibly soiled, with sediments, or blood, the facility staff did not document any changes in the Treatment Administration Record (TAR) or progress notes for the months of March, April, and May 2024. The last recorded change of the urinary catheter and bag was on April 25, 2024, which was not reflected in the TAR or progress notes as per the facility's policy and best practices. Interviews with the Wound Care Nurse (WCN) and Licensed Practical Nurse (LPN) confirmed that the urinary bag with tubing is changed only as needed and should be signed off in the TAR. However, the review of the TAR and progress notes did not show any documentation of such changes. The facility's policy on urinary catheter care, revised in February 2019, mandates changing the urinary catheter and drainage bag based on clinical indications such as infection, obstruction, or if the closed system is compromised. The lack of documentation and adherence to the policy led to the deficiency noted by the surveyors.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that residents received appropriate respiratory care in accordance with professional standards. One resident was observed using an empty oxygen cylinder for over an hour, and a CNA confirmed the cylinder was empty. Another resident's CPAP mask was repeatedly found lying on the bed or floor and not contained in a bag, as required to prevent dust collection and potential respiratory infection. The facility could not provide a policy for oxygen use, and the resident's Physician's Order Sheet indicated the need for continuous oxygen and CPAP use at bedtime.
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What surveyors actually found near you
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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 Elgin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crescent Care Of Elgin | 0.5 mi | ★★★★★ | 5 | 0 |
| Aperion Care Elgin | 2.1 mi | ★★★★★ | 2 | 0 |
| River View Rehab Center | 2.2 mi | ★★★★★ | 28 | 0 |
| The Pearl Of Fox River Valley | 2.6 mi | ★★★★★ | 13 | 0 |
| Tower Hill Healthcare Center | 2.7 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.