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 Of Elgin, The during CMS and state inspections, most recent first.
A resident with cognitive impairment had a designated POA for healthcare decisions, but facility staff facilitated the completion and release of guardianship paperwork to a non-POA family member without informing or obtaining consent from the POA, contrary to facility policy.
A resident with moderate cognitive impairment had damaged hearing aids, and the facility failed to address the grievance raised by the resident's POA in a timely manner. Despite being notified, the facility did not investigate or document the grievance until 51 days later, contrary to their policy requiring immediate action.
The facility failed to follow its hand hygiene policy during care for a resident with an indwelling urinary catheter, as a CNA used the same gloves throughout the process without proper hand hygiene. Additionally, the facility did not adhere to its water management plan for Legionella prevention, lacking documentation of temperature checks and chlorine level monitoring. These deficiencies posed a potential risk to all 121 residents.
The facility failed to provide appropriate food consistency for residents on modified diets, affecting 11 residents. Pureed meals contained hard, burnt pieces, and mechanical soft diets were served with shredded coleslaw instead of ground. This led to a resident experiencing a coughing episode due to improper food texture. The facility did not adhere to its policy and recipe guidelines for consistency-modified foods.
The facility did not follow its policy to offer pneumococcal vaccines according to CDC guidelines, affecting five residents with various medical conditions. These residents, who had previously received the PPSV23 vaccine, were not offered the subsequent PCV20 or PCV15 vaccine one year later as required. The facility's policy mandates offering vaccines per CDC guidelines, but documentation was lacking, and staff confirmed the oversight.
The facility failed to ensure residents could voice grievances without fear of retaliation, as three residents reported being discouraged by staff from complaining to surveyors. Additionally, the facility did not document a resident's grievance about missing dentures, contrary to its policy.
A facility failed to conduct a PASRR screening for a resident with mental disorders upon admission. The resident, diagnosed with schizophrenia and other mental health conditions, did not have a completed PASRR Level I screening due to incomplete documentation by the healthcare professional. The facility's policy mandates such screenings, but the process was not followed, resulting in a deficiency.
A resident's central line dressing was not changed every 48 hours as required when gauze is used under a transparent membrane. The resident, with a history of infections, had a dressing that was not changed for eight days, and the facility's practice was to change it weekly. The DON was unaware of the policy requiring more frequent changes, leading to a deficiency in care.
A facility failed to store insulin and house stock medication according to policy. An LPN found an unopened Basaglar insulin pen in a medication cart drawer instead of refrigerated, despite instructions to refrigerate until opened. The insulin had a fill date of August 10, 2024, and the resident had an active order for 60 units at bedtime. Additionally, a nurse supervisor found expired zinc sulfate capsules and multivitamins in the medication storage room. Facility policy requires refrigerated storage for certain medications and removal of expired medications.
A resident reported missing dentures since early 2024, but the facility failed to file a grievance or follow up on dental office communications regarding replacement costs. Despite a treatment plan for dentures, no progress was made due to the facility's lack of response and unclear responsibility for dental follow-up.
Failure to Notify POA Before Facilitating Guardianship Paperwork
Penalty
Summary
The facility failed to inform and involve a resident's designated Power of Attorney (POA) before facilitating the completion of guardianship paperwork for another family member. The POA, who was listed in the resident's records as the healthcare agent, responsible party, surrogate decision maker, and emergency contact, was not notified or consulted when a non-POA family member requested and received a completed guardianship evaluation report from the facility. The Social Services Director received a legal guardianship form from the non-POA family member and, without seeking authorization from the POA, passed it to the Administrator, who then facilitated its completion by the resident's physician. The completed form was subsequently provided to the non-POA family member. The resident involved was cognitively impaired, as documented by a SLUMS assessment and care plan indicating impaired judgment. Despite this, there was no documentation or expression from the resident regarding a desire to change guardianship. Both the Social Services Director and Administrator acknowledged that they should have honored the wishes of the designated POA and notified her for consent, as required by facility policy, but failed to do so.
Failure to Address Grievance Regarding Damaged Hearing Aids
Penalty
Summary
The facility failed to timely respond to a grievance raised by a resident's Power of Attorney (POA) regarding the resident's damaged hearing aids. The resident, who had moderate cognitive impairment and required bilateral hearing aids, was initially reported to have missing and subsequently damaged hearing aids. The POA first communicated this concern to the facility via email on July 30, 2024, and followed up on August 3, 2024, requesting the facility to contact her. Despite these notifications, the facility did not address the concern promptly, as the grievance was only formally documented on September 19, 2024, 51 days after the initial notification. The facility's grievance policy, which mandates immediate documentation and investigation of grievances, was not followed. The policy defines 'immediately' as within four hours, yet the facility did not investigate or interview staff regarding the incident with the hearing aids. The Administrator acknowledged that the concern was not addressed earlier because they believed the resident might have damaged the hearing aids herself and that new hearing aids had already been provided by the POA. This lack of timely response and investigation constitutes a failure to adhere to the facility's grievance policy.
Inadequate Infection Control and Water Management Practices
Penalty
Summary
The facility failed to adhere to its hand hygiene policy during the provision of care for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including dementia and cerebrovascular disease, required assistance with toileting hygiene. During an observation, a Certified Nursing Assistant (CNA) was seen using the same gloves throughout the process of emptying the resident's urinary drainage bag and providing perineal care, without changing gloves or performing hand hygiene as required by the facility's policy. The CNA did not properly clean the catheter tubing or the resident's labia, and applied protective ointment with contaminated gloves, which was against the infection prevention protocol. Additionally, the facility did not follow its water management plan for Legionella prevention. The Maintenance Director admitted to not keeping logs of temperature checks for the hot water tank, mixing valve, or kitchen/laundry water temperatures, nor checking the facility's water for chlorine levels. The facility's water management plan, which was based on CDC and ASHRAE recommendations, required systematic water flushing and monitoring of chlorine levels to prevent Legionella growth. However, the facility lacked documentation to show compliance with these measures, and the Administrator confirmed that the updated plan did not include chlorine testing, leaving the facility unaware if the control limits were being met. The facility's failure to implement its infection prevention and control program, including proper hand hygiene and water management practices, posed a potential risk to all 121 residents. The lack of adherence to established protocols for both hand hygiene and water management could lead to cross-contamination and the spread of infections, including Legionella, within the facility.
Inappropriate Food Consistency for Residents on Modified Diets
Penalty
Summary
The facility failed to provide food in the appropriate consistency for residents on specific diet orders, affecting 11 residents. During tray line service, the pureed barbeque pork riblet was observed to be grainy with black, burnt substances, and the pureed bread appeared granular. When taste-tested, the pureed meat contained hard pieces that required chewing, which is not suitable for residents on a pureed diet. The Food Service Manager and Cook acknowledged the presence of charred pieces in the pureed food. The facility's diet order sheet confirmed that several residents were on pureed diets, yet they received improperly prepared meals. Additionally, during meal rounds, a resident on a mechanical soft diet was fed shredded coleslaw instead of the required ground consistency, leading to a coughing episode. The resident, who was missing most of her teeth, struggled with the meal, which included a mechanical soft riblet on a bun and shredded coleslaw. The resident's meal ticket indicated a ground creamy coleslaw was required, but this was not provided. Other residents on mechanical soft diets also received shredded coleslaw, which was not in accordance with their dietary needs. The facility's policy and recipe guidelines for consistency-modified foods were not followed, resulting in the provision of inappropriate food textures to residents.
Failure to Offer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to adhere to its policy of offering pneumococcal vaccines in accordance with CDC guidelines, affecting five residents reviewed for immunizations. The residents, who had various medical conditions such as congestive heart failure, chronic kidney disease, Parkinson's disease, and diabetes, were not offered the appropriate pneumococcal vaccines as per the CDC's recommended schedule. Specifically, residents who had previously received the PPSV23 vaccine were not offered the subsequent PCV20 or PCV15 vaccine one year later, as required. The facility's policy, which aligns with CDC guidelines, mandates offering pneumococcal immunizations according to a specific algorithm. However, documentation was lacking to show that these residents were offered the necessary follow-up vaccines. Interviews with the Infection Preventionist Nurse and the Director of Nursing confirmed that the facility did not offer the required vaccines to the residents, despite acknowledging the CDC's guidelines for pneumococcal vaccine timing. This oversight was identified during a review of the residents' electronic medical records and immunization reports.
Failure to Uphold Resident Grievance Rights and Document Complaints
Penalty
Summary
The facility failed to uphold residents' rights to voice grievances without fear of retaliation, as evidenced by the experiences of three cognitively intact residents. During a resident council meeting, one resident expressed fear of retaliation after being asked by a staff member not to complain to the surveyor to ensure the facility passed the survey. Two other residents confirmed similar experiences, feeling intimidated and uncomfortable due to the staff's requests. The Director of Nursing was specifically mentioned as having approached residents to discourage them from voicing complaints to state surveyors, which made the residents feel watched and pressured to lie. Additionally, the facility did not adhere to its grievance policy, as demonstrated by the case of a resident who reported missing dentures. Despite the resident's cognitive intactness and having reported the issue to nursing staff, there was no documentation of the grievance in the facility's log. The Social Services Director, who is the Grievance Coordinator, was unaware of the missing dentures until the surveyor brought it to the Administrator's attention. The facility's grievance policy requires grievances to be documented and investigated, but this process was not followed in the case of the missing dentures.
Failure to Conduct PASRR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to conduct a Preadmission Screening and Resident Review (PASRR) for a resident with a mental disorder upon admission. This deficiency was identified during a survey, where it was found that the resident, who has diagnoses including schizophrenia, anxiety disorder, and major depressive disorder, did not have a completed PASRR Level I screening. The resident's PASRR request had been canceled by the state agency's contracted provider due to the healthcare professional's failure to complete the necessary documentation within the required timeframe. The facility's Admissions Director stated that all residents are supposed to receive a PASRR screening upon admission, typically conducted at the hospital, and that the facility checks to ensure screenings are completed, although the frequency of these checks is unclear. The facility's policy requires a Level I PASARR screen for all new admissions to identify potential mental disorders, intellectual disabilities, or related disorders, with referrals made to the state PASARR representative for further evaluation if necessary. However, in this case, the required screening was not completed, leading to the deficiency noted in the report.
Failure to Change Central Line Dressing Every 48 Hours
Penalty
Summary
The facility failed to ensure that a resident's central line dressing was changed every 48 hours as required when gauze is used underneath a transparent semipermeable membrane. The resident, a male with a history of local infection of the skin, sepsis, and peritoneal abscess, had an order to change the dressing weekly. However, observations revealed that the dressing was not changed for eight days, and the resident confirmed that it had not been changed recently. The dressing was found to be dirty and covered with a dirty sleeve, indicating neglect in following the proper dressing change schedule. The Director of Nursing (V2) stated that their practice was to change the central line dressing every seven days and as needed, using a central line kit that did not include the specified specialty dressing. V2 was unaware of the facility's policy requiring dressing changes every 48 hours when gauze is used under a transparent membrane, as per the intravenous Nursing Society Standards. The electronic medication administration record also confirmed that the dressing was not being changed every 48 hours, leading to a deficiency in the care provided to the resident.
Improper Storage of Insulin and Expired Medications
Penalty
Summary
The facility failed to store insulin and house stock medication in accordance with their policy. During an inspection of the medication cart on the XXX Hall East, an LPN found an unopened Basaglar insulin pen belonging to a resident stored in the drawer instead of the refrigerator, despite the package instructions to refrigerate until opened. The insulin pen had a pharmacy fill date of August 10, 2024, and the resident had an active order for 60 units of Basaglar insulin at bedtime daily. Additionally, in the East Medication Storage room, a nurse supervisor discovered expired zinc sulfate capsules and multivitamins in the cabinet where house stock medications are stored. The zinc sulfate capsules had an expiration date of October 2023, and the multivitamins had an expiration date of July 2024. The facility's policy on medication storage requires medications needing refrigeration to be kept at temperatures between 36F and 46F and mandates the removal and destruction of expired medications from the active supply.
Failure to Assist Resident with Denture Replacement
Penalty
Summary
The facility failed to have the required policy regarding missing or lost dentures and financial responsibility, as per regulation 483.55(b)(4), and did not assist a resident in need of dentures to obtain them. The resident, who was cognitively intact and required assistance with various activities of daily living, reported missing her dentures since early 2024. Despite informing the nursing staff, no grievance was filed on her behalf, and the facility did not follow up on the dental office's communication regarding the cost and replacement of the dentures. The resident's dental visit notes indicated a treatment plan for dentures, but the facility did not respond to the dental office's email detailing the costs, resulting in no progress on the denture replacements. The facility's policy required prompt referral for lost dentures, but there was a lack of clarity on who was responsible for following through with dental treatment plans. The facility did not provide a policy on lost dentures or financial responsibility, contributing to the deficiency.
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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) |
|---|---|---|---|---|
| Highland Oaks | 0.6 mi | ★★★★★ | 0 | 0 |
| The Pearl Of Fox River Valley | 1.4 mi | ★★★★★ | 13 | 0 |
| River View Rehab Center | 1.4 mi | ★★★★★ | 28 | 0 |
| Aperion Care Elgin | 1.5 mi | ★★★★★ | 2 | 0 |
| Avondale Estates Of Elgin | 1.9 mi | ★★★★★ | 0 | 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.