Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 The Pearl Of Fox River Valley during CMS and state inspections, most recent first.
Two residents at high risk for pressure ulcers did not receive required heel offloading interventions as specified in their care plans and facility policy. Staff failed to consistently use offloading devices or elevate heels while the residents were in bed, resulting in noncompliance with prescribed pressure ulcer prevention protocols.
The facility failed to provide adequate supervision and implement required safety interventions for four residents with significant cognitive and physical impairments. Two residents with dysphagia and severe cognitive deficits were left unsupervised during meals despite orders for 1:1 supervision, a resident at high risk for falls was transferred without a gait belt, and another resident with a traumatic brain injury was not consistently monitored as required by her care plan. These actions and omissions resulted in deficiencies related to accident hazard prevention and resident safety.
Multiple residents with indwelling catheters did not receive consistent daily peri care or catheter cleaning, and staff were observed placing catheter drainage bags on the floor or above bladder level during transfers and care. These actions were contrary to the facility's infection control policy and care plans, which required daily catheter care and proper positioning of drainage bags to prevent infection.
Eight residents on pureed diets did not receive a pureed dinner roll during a lunch meal as required by their dietary orders and the facility's menu. Dietary staff failed to prepare and serve the pureed bread, and both the Dietary Manager and RD confirmed the omission was due to staff oversight, resulting in the residents not receiving the prescribed carbohydrate portion.
A resident's dignity was not maintained when a housekeeper and a CNA argued in the resident's presence about who was responsible for cleaning up feces in the bathroom, and the housekeeper took unauthorized photographs of the soiled area. The resident, who required significant assistance due to multiple medical conditions, felt embarrassed by the incident, which violated facility policy on privacy and dignity.
A resident with multiple chronic conditions and moderate cognitive impairment was allowed to keep prescription Viagra at the bedside and self-administer the medication without a current assessment, physician order, or care plan as required by facility policy. Nursing staff confirmed the medication was left for the resident to take as needed, and documentation showed no recent evaluation of the resident's ability to self-administer medications.
Two residents with cognitive impairments and multiple chronic conditions did not receive compression stockings as ordered by their physicians. Staff, including CNAs and a wound care nurse, were unaware of the orders, and documentation indicated the stockings were applied when they were not. The facility's policy requires following physician orders, but this was not done for these residents.
A resident with chronic medical conditions was observed splitting and self-administering a prescribed diuretic tablet in two separate doses, rather than taking it as ordered. Staff interviews confirmed that medication administration protocols were not followed, as the nurse did not remain with the resident to ensure the medication was taken as prescribed.
A CNA failed to wear a gown and did not change gloves during high-contact care for a resident on Enhanced Barrier Precautions (EBP) with an indwelling urinary catheter. The CNA touched multiple surfaces with contaminated gloves and only donned a gown after being reminded by another staff member. Facility policy and the DON confirmed that both gown and gloves are required for such care activities to prevent cross-contamination.
A pharmacist's Medication Regimen Review (MRR) failed to identify the omission of a resident's thyroid medication, Levothyroxine, upon readmission to the facility. Despite the presence of hospital documents in the resident's EMR, the omission was not caught during the initial or subsequent monthly MRRs. The resident experienced symptoms related to the missed medication, and her physician had to restart the medication 79 days later.
A resident with hypothyroidism did not receive her prescribed thyroid medication for 79 days due to a transcription error upon readmission to the facility. The omission was discovered after the resident exhibited symptoms of untreated hypothyroidism, and her community physician noted elevated TSH levels. The facility's policies for verifying medication orders upon readmission were not followed.
A resident with Multiple Sclerosis and other conditions was injured when a faulty shower chair abruptly stopped, causing her to fall and fracture her legs. The facility's shower chairs were in poor repair, with issues like locking wheels and difficulty moving over floor strips, which staff had been aware of. Despite warnings in the manufacturer's manual, the chairs continued to be used, leading to the incident.
The facility failed to document and resolve grievances from residents, including concerns about a confused peer wandering into rooms and the poor condition of shower chairs. Despite residents reporting these issues, no concern forms were generated, and the facility's grievance policy was not followed.
The facility failed to obtain weights as ordered for five residents with various medical conditions, including heart failure and diabetes. Despite physician orders for daily or weekly weights, documentation showed significant gaps in weight records. The DON confirmed that staff are expected to follow orders and document refusals, aligning with the facility's policy.
The facility failed to provide properly pureed foods for six residents on pureed diets. A resident was served lumpy pureed beef with visible solid particles, which the Food Service Director confirmed was not fully pureed. The facility's policy requires pureed foods to be smooth, like pudding or mashed potatoes, but the served beef did not meet this standard.
A facility failed to obtain timely treatment orders for a newly admitted resident with multiple pressure ulcers. The resident's medical record showed several pressure ulcers upon admission, but treatment orders were not obtained until days later. Interviews with staff revealed that the admitting nurse did not notify the physician for treatment orders, contrary to facility policy, resulting in a deficiency.
The facility failed to provide proper indwelling catheter care for three residents, resulting in cloudy urine and sediments in the catheter tubing, indicating potential infection risks. Despite care plans requiring regular catheter maintenance, the conditions persisted over several days. Additionally, one resident's catheter was not secured, increasing the risk of trauma. The facility's policies for catheter care and securing devices were not followed, contributing to the deficiency.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement pressure ulcer prevention measures for two residents identified as being at high risk for skin breakdown. One resident with diagnoses including Parkinson's disease, dementia, and hypertension was observed lying in bed with heels resting directly on the mattress, despite care plan interventions specifying that heels should be offloaded. Staff present at the time stated that all necessary care had been completed, and no further interventions were provided to offload the resident's heels. The resident's care plan and risk assessments documented the need for heel offloading due to high risk for pressure ulcers, but this intervention was not followed during the observation period. Another resident with severe cognitive impairment, chronic kidney disease, Alzheimer's disease, and heart failure was also observed lying in bed with heels resting on the mattress, while prescribed offloading boots were not in use and instead placed on a chair in the room. Staff provided inconsistent explanations regarding the use of offloading devices, with one CNA stating the boots were only needed in the afternoon, while another CNA clarified that offloading should occur at all times when the resident is in bed. The facility's policy and care plans required consistent offloading of heels to prevent pressure ulcers, but these measures were not implemented as observed.
Failure to Supervise and Implement Safety Measures for Residents at Risk
Penalty
Summary
The facility failed to provide adequate supervision and implement safety measures for multiple residents, resulting in deficiencies related to accident hazards and prevention. One resident with severe cognitive impairment, metabolic encephalopathy, and dysphagia was observed eating a pureed diet alone in his room without staff supervision, despite orders and speech therapy recommendations for 1:1 supervision at all meals due to swallowing difficulties. Staff interviews confirmed that this resident should not have been left unsupervised while eating, as he required constant reminders and cueing to ensure safe swallowing practices. Another resident with a history of unsteadiness, falls, and maximum assist needs for transfers was transferred from bed to wheelchair by a CNA without the use of a gait belt, contrary to facility policy and care plan instructions. The CNA held the resident under the arms instead, and the resident reported that gait belts were only used during therapy sessions, not in her room. The Director of Rehab confirmed that a gait belt should be used at all times for this resident due to her high fall risk and potential for sudden weakness during transfers. Additionally, a resident with dementia, hemiplegia, and dysphagia was repeatedly observed eating pureed meals alone in her room with the privacy curtain drawn, making her invisible from the hallway. Both the facility dietician and DON stated that this resident required supervision at all meals due to her high risk of choking and aspiration. Another resident with a traumatic brain injury and high fall risk was found alone in her room with the door and blinds closed, contrary to posted safety instructions and care plan interventions. The care plan had not been updated to reflect a recent fall with injury, and required fall precautions were not consistently maintained.
Failure to Provide Proper Catheter Care and Maintain Infection Control
Penalty
Summary
The facility failed to provide appropriate catheter care and maintain proper infection control practices for four out of five residents reviewed for catheters. Observations revealed that one resident's indwelling urinary drainage bag was placed on a hook on her nightstand, and she reported that staff only emptied the drainage bag and did not provide daily peri care or clean the catheter tubing as required. Staff interviews confirmed that peri care and catheter cleaning were inconsistently performed, with some staff indicating that the resident was responsible for her own care, despite her care plan indicating substantial assistance was needed. Another resident was observed with a catheter drainage bag lying on the floor, which staff acknowledged was against infection control protocols. Additional observations showed improper handling of catheter drainage bags during transfers and personal care, including placing the bag above the level of the bladder and on the resident's lap, leading to urine backflow in the tubing. Staff interviews confirmed awareness that the drainage bag should always be kept below the bladder to prevent backflow, but this practice was not consistently followed. Documentation for the residents involved showed significant medical histories, including multiple sclerosis, chronic kidney disease, Parkinson's disease, Alzheimer's disease, and neuromuscular dysfunction of the bladder. Care plans for these residents identified the risk of infection related to indwelling catheters and outlined the need for proper catheter care and infection control measures. The facility's own policy required daily catheter care, keeping drainage bags off the floor, and maintaining the bag below bladder level, but these procedures were not consistently implemented as observed and reported.
Failure to Provide Pureed Dinner Rolls to Residents on Pureed Diets
Penalty
Summary
The facility failed to ensure that residents on pureed diets received a pureed dinner roll during the lunch meal, as required by the menu and residents' dietary orders. During an initial kitchen tour and subsequent meal preparation observation, it was noted that no pureed dinner rolls were provided to any of the eight residents on pureed diets. The Dietary Manager confirmed that the lunch meal was supposed to include herbed turkey, California blend vegetables, mashed potatoes and gravy, cookies, and dinner rolls, but the pureed version of the dinner roll was omitted for those on pureed diets. Interviews with the Dietary Manager and Registered Dietitian revealed that the omission was due to staff forgetting to prepare the pureed dinner rolls. The Registered Dietitian emphasized the importance of serving the pureed bread to meet residents' nutritional needs, specifically carbohydrate intake, and clarified that a larger portion would be necessary if the bread was combined with other items. The facility's menu and policy required all food items, including pureed dinner rolls, to be served as listed, but this was not followed for the lunch meal in question.
Failure to Maintain Resident Dignity During Staff Dispute and Unauthorized Photography
Penalty
Summary
Staff failed to maintain the dignity of a resident when a housekeeper and a CNA engaged in a dispute in front of the resident and his roommate regarding who was responsible for cleaning up feces in the resident's bathroom. The incident was witnessed by both residents, with one reporting feeling embarrassed and down as a result. The housekeeper took multiple photographs of the soiled bathroom to send to her supervisor, further compromising the resident's privacy. The discussion and actions occurred in the presence of the resident, rather than in a private area, and the taking of photographs of the resident's room was not permitted by facility policy. The resident involved had multiple diagnoses, including Parkinson's disease with dyskinesia, unsteadiness, lack of coordination, and was dependent on staff for toilet hygiene and transfers. He was frequently incontinent of urine and occasionally incontinent of bowel, requiring substantial to maximal assistance. The facility's policy required staff to respect residents' privacy and dignity at all times and prohibited sharing health information or taking photographs of residents' rooms without consent. The administrator was unaware of the incident until informed by the surveyor.
Failure to Follow Policy for Self-Administration of Medication
Penalty
Summary
The facility failed to follow its policy regarding self-administration of medications for a resident with multiple diagnoses, including congestive heart failure, hypertension, diabetes mellitus, cardiomyopathy, and stage three kidney disease. The resident, who had moderate cognitive impairment, was observed with a vial of prescription Viagra on his bedside table and reported self-administering the medication for the past two to three months. Nursing staff confirmed that the medication was left at the bedside for the resident to take as needed, despite facility policy requiring a physician's order, a care plan, and an assessment of the resident's ability to self-administer medications safely. Record review revealed that the only assessment of the resident's ability to self-administer medication was over a year old and related to an inhaler, not the current medication in question. There was no current physician order or care plan authorizing self-administration of Viagra or allowing the medication to be kept at the bedside. Facility leadership confirmed that the required assessment, physician order, and care plan were not in place, and that the resident's ability to self-administer had not been evaluated as required by policy.
Failure to Apply Compression Stockings per Physician Orders
Penalty
Summary
The facility failed to apply compression stockings as ordered by physicians for two residents with cognitive impairments and multiple medical diagnoses. For one resident with Parkinson's disease, dementia, and other chronic conditions, physician orders required compression stockings to be applied to both lower extremities. However, during multiple observations, the resident was found without compression stockings, and both the wound care nurse and CNA were unaware of the order. The treatment administration record indicated the stockings were documented as applied, but direct observation contradicted this. The Director of Nursing confirmed that physician orders should be followed at all times and that documentation should reflect actual care provided. Similarly, another resident with severe cognitive impairment and diagnoses including metabolic encephalopathy, chronic kidney disease, Alzheimer's disease, and congestive heart failure had physician orders for daily application and removal of compression stockings. Observations on consecutive days found the resident without compression stockings, and several CNAs, including agency staff, were unsure of the resident's need for them despite signage in the room. The facility's policy requires adherence to physician orders, but staff failed to ensure the prescribed treatment was provided.
Failure to Ensure Proper Administration of Physician-Ordered Medication
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were administered as ordered for a resident with multiple diagnoses, including cellulitis, chronic kidney disease, edema, and paranoid schizophrenia. The resident had a physician's order for Bumetanide (Bumex) 2 mg tablet to be taken by mouth each morning for fluid retention, with the medication scheduled for administration at 6 AM daily. Documentation showed the medication was signed as given at the scheduled time. However, direct observation revealed that the resident kept the medication at his bedside, split the tablet in half, and self-administered it in two separate doses, contrary to the prescribed order. Interviews with staff confirmed that nurses are required to verify medication orders, bring medications directly to the resident, and remain with the resident until the medication is swallowed. The Director of Nurses stated that the resident should not be splitting the dose and that the medication should be taken as ordered. The facility's Medication Pass policy requires staff to sign the MAR after administering medication but did not provide additional policies regarding proper medication administration. The failure to ensure the medication was administered as ordered resulted in a deficiency.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow Enhanced Barrier Precautions (EBP) during catheter care for a resident with multiple diagnoses, including metabolic encephalopathy, chronic kidney disease stage 4, Alzheimer's disease, major depressive disorder, and congestive heart failure. The resident was on EBP due to the presence of an indwelling urinary catheter, as documented in the care plan and indicated by signage at the resident's doorway. The CNA entered the resident's room wearing gloves but did not don a gown while performing high-contact care activities, such as emptying the catheter drainage bag. The CNA also failed to change gloves after providing catheter care and proceeded to touch multiple surfaces, including the shared bathroom door, bed remote, and the resident's clean clothing, without changing gloves. The deficiency was further substantiated by staff interviews and facility policy review. Another CNA reminded the staff member to wear a gown, at which point the gown was applied only for transferring the resident out of bed. The Director of Nursing confirmed that all staff are required to wear both gown and gloves during high-contact care for residents on EBP and to change gloves after catheter care to prevent cross-contamination. The facility's policy, revised on 6/30/25, mandates the use of gown and gloves for high-contact activities involving residents with indwelling medical devices, regardless of colonization status, to reduce the transmission of multi-drug-resistant organisms.
Pharmacist Fails to Identify Omitted Thyroid Medication
Penalty
Summary
The pharmacist's Medication Regimen Review (MRR) failed to identify a transcription omission of a resident's thyroid medication, Levothyroxine, for her hypothyroidism diagnosis at the time of her readmission. The resident was discharged from the facility and readmitted after an emergency room visit, with her hospital documents uploaded to her electronic medical record (EMR). Despite the presence of these documents, the pharmacist did not catch the omission of the thyroid medication during the MRR conducted on the resident's readmission and in subsequent monthly reviews. The resident experienced symptoms such as confusion, fatigue, and ocular issues, which were later attributed to the missed thyroid medication. Her physician noted an elevated thyroid-stimulating hormone (TSH) level and restarted her prior dose of Levothyroxine 79 days after the omission. The pharmacist manager consultant confirmed that the medication was missed during the MRRs and expressed uncertainty about whether the hospital documents were reviewed by the pharmacists. The facility's policy mandates monthly MRRs to ensure medications promote the resident's highest level of function, but this was not achieved in this case.
Failure to Administer Thyroid Medication for 79 Days
Penalty
Summary
The facility failed to transcribe a resident's thyroid medication as ordered, resulting in the medication not being administered for 79 days. The resident, who had an active diagnosis of hypothyroidism, was discharged and readmitted to the facility after an emergency room visit. Upon readmission, the resident's Levothyroxine Sodium, a thyroid hormone medication, was omitted from her medication regimen. This oversight was discovered when the resident's community physician noted elevated thyroid-stimulating hormone (TSH) levels and symptoms consistent with untreated hypothyroidism, such as confusion, fatigue, and ocular issues. The resident's electronic medical record (EMR) and electronic medication administration record (EMAR) showed that the Levothyroxine was last administered before discharge and was not restarted upon readmission. The facility's Director of Nursing acknowledged the error, stating that the medication was omitted and restarted at a lower dose than previously prescribed. The facility's policies required verification of hospital transfer orders with the attending physician upon admission and readmission, which was not adhered to in this case.
Unsafe Transport in Shower Chair Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transport of a resident, R24, to the shower room, resulting in a fall and serious injuries. R24, a cognitively intact female with Multiple Sclerosis, Chronic Pain, and Polyneuropathy, required substantial assistance for mobility. On the day of the incident, a CNA transported R24 using a PVC shower chair instead of a wheelchair. The chair abruptly stopped at a metal transition strip on the floor, causing R24 to fall and sustain fractures to her right femur and left tibia and fibula. The incident report and interviews revealed that the shower chairs were in poor repair, with issues such as wheels locking unexpectedly and difficulty moving over floor strips. Staff members, including CNAs and the Director of Nursing, acknowledged the problems with the shower chairs, noting that they were hard to push and could tilt when encountering floor strips. Observations confirmed that the chairs were stiff and had a brown substance around the wheels. The manufacturer's manual for the shower chairs advised against using the chairs if they appeared unstable or if the casters were rusted. Despite these warnings, the facility continued to use the faulty chairs, leading to the accident involving R24.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to document and promptly resolve grievances raised by residents, as evidenced by the experiences of five residents. During a resident meeting, several residents expressed that their concerns about a confused peer wandering into their rooms had not been addressed, despite being raised in a previous meeting. The facility's activity director, who attended the meetings and took minutes, did not create a concern form for this issue. The facility administrator acknowledged awareness of the issue but did not ensure that a grievance form was completed as per the facility's policy. Additionally, a resident reported ongoing issues with the condition of shower chairs, which had been a concern for over two years. Despite reporting these issues to multiple CNAs, no concern forms were generated for this resident's complaints. The facility's grievance policy outlines the process for addressing grievances, including documentation and investigation, but these procedures were not followed in these instances, leading to unresolved resident concerns.
Failure to Obtain Resident Weights as Ordered
Penalty
Summary
The facility failed to obtain resident weights in accordance with physician orders for five residents. Resident R21, with multiple diagnoses including heart failure and chronic kidney disease, had a physician order for daily weights starting May 28, 2024. However, weights were only recorded sporadically, with significant gaps between May 29 and July 6, 2024. Similarly, Resident R60, diagnosed with chronic venous hypertension and congestive heart failure, had an order for daily weights from June 13, 2024, but weights were documented only on select days, not daily as required. Resident R14, with conditions such as Parkinson's disease and dementia, had a daily weight order from May 8, 2024, but was not weighed or refused to be weighed on multiple days across May, June, and July. Resident R37, with diagnoses including spinal fracture and COPD, had an order for weekly weights, but was not weighed on three specified weeks in June. Lastly, Resident R61, with a history of stroke and congestive heart failure, had a daily weight order from June 27, 2024, but was not weighed or refused on several days in June and July. The Director of Nursing acknowledged the expectation for staff to follow physician orders and document refusals, as per the facility's policy revised on June 6, 2024.
Failure to Provide Properly Pureed Foods
Penalty
Summary
The facility failed to provide pureed foods to a smooth consistency for six residents on pureed diets. On July 8, 2024, a resident was observed eating a lunch meal that included pureed beef, which appeared lumpy with visible solid particles. The Food Service Director, upon observing and tasting the pureed beef, confirmed that it was not completely pureed and required further processing. The facility's policy, reviewed in June 2024, specifies that pureed foods should reach a smooth consistency similar to pudding or mashed potatoes. However, the pureed beef served did not meet this standard, as it contained small pieces of unpureed beef that required chewing.
Failure to Obtain Timely Treatment Orders for Pressure Ulcers
Penalty
Summary
The facility failed to obtain treatment orders for a newly admitted resident with pressure ulcers, leading to a deficiency in care. The resident, identified as R256, was admitted with multiple diagnoses, including several pressure ulcers. Upon admission, the resident's electronic medical record indicated the presence of two stage three pressure ulcers, two unstageable pressure ulcers, and one deep tissue pressure injury. However, it was found that no treatment orders were obtained for these pressure ulcers until several days after admission. Interviews with facility staff, including the Wound Care Nurse and the Director of Nursing, revealed that the admitting nurse did not notify the physician to obtain treatment orders for the pressure ulcers upon the resident's admission. The facility's policy requires that wound care treatment be initiated upon identification of a wound with a physician's order, but there was no documentation of pressure ulcer treatment for the resident on the first three days following admission. This lack of timely action and documentation led to the deficiency noted in the report.
Inadequate Indwelling Catheter Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide adequate indwelling catheter care for three residents, leading to potential infection risks. Resident 1, with a history of hemiplegia, hemiparesis, and epilepsy, was observed multiple times with cloudy urine and yellow sediments in the catheter tubing, indicating a lack of proper catheter maintenance. Despite having a care plan that required catheter care every shift, the resident's catheter condition remained unchanged over several days. Similarly, Resident 70, diagnosed with Parkinson's disease and urinary retention, was found with cloudy urine and sediments in the catheter tubing on multiple occasions. The registered nurse acknowledged the need for intervention but did not take immediate action to address the issue. Resident 86, with a complex medical history including ventricular tachycardia and chronic kidney disease, was also observed with cloudy urine and sediments in the catheter tubing. Additionally, the resident was seen attempting to pull the catheter tubing, which was not secured, increasing the risk of catheter-related trauma. The facility's policy required catheter irrigation to prevent obstruction and the use of an anchor device to secure the catheter, but these measures were not implemented. The Director of Nursing confirmed the need for catheter irrigation and securing devices, yet these actions were not taken, 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) |
|---|---|---|---|---|
| River View Rehab Center | 0.5 mi | ★★★★★ | 28 | 0 |
| Aperion Care Elgin | 0.8 mi | ★★★★★ | 2 | 0 |
| Pearl Of Elgin, The | 1.4 mi | ★★★★★ | 1 | 0 |
| Highland Oaks | 1.7 mi | ★★★★★ | 0 | 0 |
| Crescent Care Of Elgin | 2.1 mi | ★★★★★ | 5 | 0 |
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