Inspection visit

InspectionAugust 16, 2023

The Pearl of Fox River ValleyCMS #14569910 citations on this visit

10 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review the facility failed to ensure resident grievances/concerns were responded to in a timely manner for 2 of 5 residents (R18, R28) reviewed for grievances in the sample of 18. The findings include: On 8/15/23 at 10:30 AM, during the resident council meeting R28 said she filed a grievance 5 weeks ago with social services about some missing clothing items and until yesterday when You guys came no one had gotten back to me about any of them. R28 said she kept a copy of the grievances she had filed. R28 gave the surveyor copies of her grievance/concern forms and those are dated 7/8/23 and indicate she was missing clothing items, a mechanical lift sling she had personally purchased, and also about clothing that was damaged in the laundry. During the same resident council meeting R18 said she also has filed a grievance form that no one had followed up on. On 8/16/23 at 8:15 AM, R18 said she had filed a grievance/concern form about missing remote controls and clothing a few weeks ago back in July 2023 and no one has yet talked with her about any of it. R18 said she left the concern form up front as they are instructed to, and did not make a copy of it. The facility provided grievance forms show a new form was completed by V1 (Administrator) for R28's concerns (from 7/8/23) on 8/14/23. There was no concern form in the binder for R28's 7/8/23 grievance. There was no concern form in the binder for R18's grievance she filed about the missing clothing and remote controls. On 8/15/23 at 1:30 PM, V2 (Director of Nursing) said the facility procedure on grievances is that once a grievance form is completed it is given to the responsible department head to follow up on and this should be done timely probably within 3-5 days, and if the department head is not able to resolve it the grievances are forwarded to V1. On 8/15/23 at 1:41 PM, V3 (Maintenance Director) said he does receive the grievances about missing laundry items and responds to them and if they cannot find the missing items they forward their concern form on to social services. V3 said he has no current grievances in his office. On 8/15/23 2:39 AM, V4 (Social Services designee) said she received a copy of the concern form that R28 had previously filed (about a month ago) she gave it to (V3) and never received the form back from him. V4 also said when she gets the completed forms back she tears them up. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 12 Event ID: 145699 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 8/16/23 at 8:55 AM, V1 said she was not aware of R28's grievance that she filed on 7/8/23 until 8/14/23 and 5 weeks is too long for a resident to wait for a response back from the facility. The facility provided grievance policy revised on 7/28/23 states, It is the facility's policy to comply with the federal regulations regarding grievance process and resolution . All written grievance decisions will include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective actions taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. Event ID: Facility ID: 145699 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assist a resident with ambulation and accurately document his progress to ensure his ability to ambulate did not diminish. Residents Affected - Few This applies to 1 of 8 residents (R41) reviewed for restorative services in the sample of 18. The findings include: On 8/14/23 at 10:00 AM R41 was lying in bed, dressed in a gown. Resident stated that he has not been up to walk in a long time and would like to be able to walk more. On 8/16/23 at 8:20 AM V15 (Occupational Therapist) stated, He was walking when he was working with us in May. You will have to talk to restorative about what he is doing now. On 8/16/23 at 8:45 AM V16 (CNA-Restorative) stated, We walk with him with the prosthesis or he rides the bicycle. He goes at least twice a week. He is doing ok. He is very forgetful and he says we are not seeing him but we are. On 8/16/23 at 10:00 AM R41 was dressed in a gown, hair uncombed. Resident states he was not walked yesterday or today. R41 stated, No I haven't walked. They ask me if I want to get up and I tell them, for what? to sit in another chair, No, I don't want to do that, but I want to walk. R41's Follow-Up Question Report showing R41's restorative ambulation and range of motion program printed at 9:04 AM on 8/16/23 shows that on 8/16/23 at 6:58 AM, V12 (CNA- Restorative) spent 15 minutes doing active range of motion with R41 and 15 minutes of ambulation. While ambulating, R41 was able to walk 100 feet with extensive assist of 2 staff. On 8/16/23 at 10:35 AM V12 (CNA- Restorative) stated, I haven't seen him yet today. I always document on my people I am going to see first thing in the morning and then I usually walk with him after breakfast. We can go see him now. On 8/16/23 at 10:41 AM R41 was approached by V12 and told he was going to go for a walk. R41 stated to V12, This is very strange. Someone keeps asking me if I want to get up and I tell them for what? V12 stated, We are going to walk, it is Wednesday. After pericare and dressing V12 and V13 (CNA) assisted R41 to stand into his prosthetic right leg. When the leg was secure V12 and V13 explained to R41 how to turn and sit in his wheelchair. V12 seemed unaware of R41's visual impairment. V12 took R41 in his wheelchair to the hallway. Using a gait belt V12 assisted R41 to stand and R41 began to walk down the hallway very slowly. V12 asked R41 several times if he wanted to sit down and stated to R41 that he seemed very weak today. R41 stated, I am so weak because I have not done this is so long. V12 did not respond to R41's statement. R41 was able to walk with assistance of 1 staff (V12) for about 25 ft with 3 rest breaks. V12 offered to take R41 to the therapy room to use the bike and R41 agreed. V12 stated, When we give him the option a lot of times he does not even try to walk. I will go back and strike out the charting that I already put in and re-enter it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/16/23 at 11:49 AM V10 (RN- MDS/Acting Restorative RN) stated, (R41) is alert and oriented but forgetful. I looked and he should be walked and have ROM 3-6 times a week. We probably need to update his care plan- right now I am only helping with the Restorative. The Managers (us) we should be overseeing the restorative CNAs. The restorative aids or the restorative nurse will let me know if something is not working for a resident. We have been having problems with regular CNAs doing the Restorative programs. The documentation should be done after the care is provided. About 3 weeks ago, the Restorative person quit. I was the restorative nurse about 1 year ago. We do Quarterly assessments for restorative or as needed but I looked and (R41's) last assessment was in January. R41's Physical Therapy Discharge summary dated [DATE] shows that R41 was able to walk 150 feet with supervision or touching assistance. R41's Minimum Data Set assessment dated [DATE] shows that R41 has no cognitive impairment. R41's Care Plan dated 5/18/23 states, Nursing Rehab: Able to walk 100-125 feet with supervision to one person limited assist using Front Wheeled [NAME] 3-6- days/week as tolerated. The facility policy entitled Restorative Nursing Program last reviewed on 7/28/23 shows, Appropriate nursing and restorative services consistent to the resident's functional needs must be provided . This same policy shows, The Restorative Programs shall be evaluated on a quarterly basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure that a resident's non-pressure wound dressings were applied as ordered. Residents Affected - Few This applies to 1 of 4 residents (R63) reviewed for for non-pressure wounds in the sample of 18. The findings include: On 8/14/23 at 10:34 AM R63 was siting in his recliner in his room watching television. R63 had his legs elevated on the foot rest. R63's lower legs (below his knees) were swollen and red and had multiple scabs and areas of open skin. R63 stated, I have one complaint. I took a shower on Friday night and the nurse refused to wrap my legs. She said it was not her job and the girl could do it on Monday. My legs have not been wrapped all weekend. On 8/14/23 at 11:38 AM V9 (Wound Nurse LPN) stated, The nurse texted me this morning and I just saw the text. We changed the dressings on Friday so unless they showered him after that, we changed them. At 11:45 AM Surveyor entered R63's room with V9 and V14 (Wound Tech-CNA). R63 repeated the same story about the nurse refusing to wrap his legs on Friday and told him they can do it on Monday so therefore he sat all weekend with no dressings on his legs. R63 stated that his legs were very red and stated that his legs feel much better when they are wrapped. V9 did not respond to R63's comments. V9 cleansed R63's legs with normal saline then applied a calcium alginate to the open areas, covered 2 areas with abdominal pads, wrapped the legs with kerlix gauze and then applied ace wraps to both legs. V9 stated the Ace wraps were to hold the dressings in place and to help with the swelling in the R63's legs. R63 then repeated his story again and V9 assured R63 that she would look into what happened on Friday and find out why the dressings were not applied. On 8/14/23 at 12:25 PM V9 stated, I found out that he refused to have anyone change the dressings but me. They tried to do it on Friday and he thought I would do it the next day (Saturday). (V9 works Monday -Friday) I went in and talked to him and explained that he can't refuse to have his dressings done just because I am not here and he said he wouldn't do that again. On 8/15/23 at 8:45 AM R63 stated, I didn't refuse anything. No one said a word to me. The CNA took the dressings off before my shower and the nurse refused to put them back on. On 8/14/23 R63's EMR (Electronic Medical Record) was reviewed and there was no documentation of R63's refusal to have his dressings done. R63's Treatment Administration Record also showed that his wound dressings were not signed out as completed on Saturday 8/12 or Sunday 8/13. R63's Treatment Administration Record for August 2023 shows that R63 is to have daily dressing changes to his Left ankle, Left dorsal foot distal, left lower anterior leg, right dorsal foot, right lateral foot, right lower leg, right medial ankle, right medial foot and right medial lower leg. R63's Minimum Data Set Assessment of 6/26/23 shows that R63 has minimal cognitive impairment. The facility policy entitled Skin Care Treatment Regimen last reviewed on 7/28/23 states, Routine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 daily wound care treatment/ dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to identify and assess two resident's pressure wounds prior to them being a Stage 3 and Stage 4 pressure wound. Residents Affected - Few This applies to 2 of 6 residents (R64 and R1) reviewed for pressure wounds in a sample of 18. The findings include: 1. On 8/15/23 at 2:29 PM, R64 was lying in bed, dressed in a gown, asleep. V9 (Wound Care LPN) entered the room to assess R64's sacral wound and change the dressing with the wound care physician and V14 (Wound Tech- CNA). R64 was assisted to turn onto her right side and V9 removed the old dressing. R64 has a baseball sized open wound on her sacrum. The area appeared clean with no signs of infection. The area was red with a beefy appearance and upon physician assessment also showed to have undermining. Resident does not appear to have pain with assessment or dressing change. The area was cleaned with normal saline and a clean dressing was applied. R64's Progress Notes dated 5/31/23 states, Resident is alert in bed with stage 2 on buttock, treatment applied. Endorsed to Am nurse to have treatment team to follow-up. R64's Wound Evaluation and Management Summary dated 6/6/23 shows that R64 has a Stage 4 Pressure Wound to her sacrum- full thickness. The wound is described as 8.4 x 13.8 x 0.4cm with 80% thick adherent devitalized necrotic tissue, 10% Granulation tissue and 10% Skin with Moderate Serous Exudate. This document also shows that the wound required surgical excisional debridement was completed on 6/6/23. R64's Initial Wound assessment dated [DATE] shows that R64's wound is a facility acquired pressure ulceration identified on 5/31/23. The wound is described as unstageable, 25% bright pink or red and 75% Necrotic, hard, firm, adherent. The wound measurements show the wound as 8 x 12.5 x unknown cm. This note states, It was reported to the writer that resident was noted with skin alteration. Cleansed and treated. Wound care MD made aware R64's Physician's Order Sheet for 8/2023 shows that she was admitted to the facility on [DATE] with diagnoses including Dementia, Protein- Calorie Malnutrition, Heart Failure and Major Depression. R64's Minimum Data Set assessment dated [DATE] shows that she has severe cognitive impairment and requires extensive assist from 1-2 staff for bed mobility, personal hygiene, dressing, eating and toilet use. R64's Care Plan dated 1/4/23 shows that she was admitted to hospice on 12/31/22 for Protein- Calorie Malnutrition. On 8/16/23 at 12:43 PM, V9 stated, The CNAs do showers every week and they document on the shower sheet if they see any open skin areas and then they are supposed to report it to the nurse and then the nurse reports to me. In these 2 cases they were not reported to me. They are my front lines and I need them to report to me when they see something. I have talked to them in our Skills fair and I have tried to educate the nurses about letting me know. I can't look at the residents everyday so I really rely on the CNAs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. On 8/15/23 at 9:00 AM, R1 stated, I got it (wound on left buttocks) from staying in one position for too long. I got it here. R1's Initial Wound assessment dated [DATE] shows that R1 has a facility acquired Stage 2 Pressure wound identified on 2/22/23 on her left ischium. The wound measure 3.0 x 1.7 x 0.10 cm and is described as 100% pink or red non-granulating( tissue). This same document states, Resident noted with skin alteration with wound care interventions in place. (Wound Physician) made aware. R1's Wound Evaluation and Management Summary also dated 2/24/23 describes R1's wound as a Stage 3 Pressure wound of the left buttock- full thickness. The wound measures 2 x 4.7 x 0.2 cm, 30% granulation tissue, 30% dermis and 40% skin with light serous drainage. R1's Wound Evaluation and Management Summary dated 8/8/23 shows that R1's wound measured 1.5 x 2 x 0.2 cm, 30 % thick adherent devitalized necrotic tissue and 70% granulation tissue with moderate serous drainage. The wound progress states: Not improved. R1's Physician's Order Sheet for 8/2023 shows that R1 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Peripheral Vascular Disease and Multiple Sclerosis. R1's Minimum Data Set assessment dated [DATE] shows that R1 has no cognitive impairment and requires extensive assist of 1 staff for personal hygiene, dressing and toilet use. R1's Skin Risk assessment dated [DATE] shows that R1 scored a 14 (Moderate Risk). On 8/16/23 at 12:43 PM, V9 (Wound Care LPN) stated Her wounds were found during her skin assessment with the wound MD. The facility policy entitled Skin Care Treatment Regimen last reviewed on 7/28/23 states, It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for residents with skin breakdown. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to administer medications ordered. There were 30 opportunities with 2 errors resulting in a 6.67% error rate. Residents Affected - Few This applies to 1 of 3 residents (R58) observed during the medication pass in a sample of 18. The findings include: On 8/15/23 at 7:46 AM, V11 (RN) prepared medications to administer to R58. V11 administered 12 medications. V11 then moved on to prepare medications for another resident. V11 was asked to return to the computer screen containing R58's medications. Upon doing this V11 saw that she had missed 2 medications Calcium and Novolog Insulin. R58's Medication Administration Record for 8/2023 shows that R58 has orders for Calcium 500 + D3 tablet 500-600mg-unit 1 tablet by mouth 2 times a day at 9:00 AM and 5:00PM and Novolog Solution 100 units/ml 18 units subcutaneously before meals ordered at 8:00 AM, 11:00 AM and 4:00PM. V11 reviewed the medications, removed a bottle of Calcium 600 + D3 oral tablet 500-200mg/mcg from the medication cart and prepared to administer 1 tablet to R58. Surveyor pointed out the difference between R58's order and the medication bottle and V11 stated, This is what we have and administered the medication to R58. V11 then reviewed the order for the Novolog Insulin and stated, That is supposed to be given before meals- that is not me. V11 did not administer the Novolog insulin to R58. On 8/15/23 at 11:00 AM, R58 confirmed that she did not receive her Novolog Insulin before breakfast on 8/15/23. The facility policy entitled Medication Pass last reviewed on 7/28/23 states, It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure that a resident received her insulin as ordered. Residents Affected - Few This applies to 1 of 3 residents (R58) reviewed for significant medication errors in a sample of 18. The findings include: On 8/15/23 at 7:46 AM V11 (RN) prepared medications to administer to R58. V11 administer 12 medications. V11 then moved on to prepare medications for another resident. V11 was asked to return to the computer screen containing R58's medications. Upon doing this V11 saw that she had missed R58's Novolog Insulin order. R58's Medication Administration Record for 8/2023 shows that R58 has orders for Novolog Solution 100 units/ml 18 units subcutaneously before meals ordered at 8:00 AM, 11:00 AM and 4:00PM. V11 reviewed the order for the Novolog Insulin and stated, That is supposed to be given before meals- that is not me. V11 did not administer the Novolog insulin to R58. On 8/15/23 at 11:00 AM R58 confirmed that she did not receive her Novolog Insulin before breakfast on 8/15/23. The facility policy entitled Medication Pass last reviewed on 7/28/23 states, It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure resident medications were stored at the required temperature for 4 of 4 residents (R2, R31, R34, R57) reviewed for medication storage in the sample of 18. The findings include: On 8/15/23 at 10:50 AM, On the 100 south hall in the medication room/south cubex room behind the nurses station was a black refrigerator with two different thermometers inside the refrigerator. One showed 50 degrees and the other showed 56 degrees Fahrenheit. Items stored in the refrigerator were the facilities Ativan E-Kit with contents of Lorazepam injections solution (anti anxiety medication). Aplisol TB solution multi use vial, R2's and R34's lorazepam solution, R31's Humalog kwik pen insulin and R57 Aspart kwik pen insulin. When the thermometers were observed by this surveyor and V5 (Infection Preventionist) IP and when asked about the temperatures V5 said Oh that is a pretty high temperature for the fridge it should be at 40 degrees. It is pretty warm in there for a fridge. The facilities refrigerator logs for the south cubex room on the 100 hall showed for June 2023 there were 13 of 30 days, July 2023 there were 14 of 31 days, and August 2023 there were four days including the 15th of the month with no documentation of the refrigerators temperatures being checked and recorded. The facility's refrigerator log showed daily temperatures must be +/-2 of normal, refrigerator range 33-40 degrees . The facility's medication storage, labeling, and disposal policy showed it is the facility's policy to comply with federal regulations in storage .of medications. 3. Medications will be stored safely under appropriate environmental controls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure housekeeping staff wore the correct Personal Protective Equipment (PPE) when cleaning a contact isolation room which applies to 1 of 18 residents (R61) reviewed for infection control in a sample of 18. Residents Affected - Few The findings include: R61's Face sheet printed on 8/16/23 showed R61 was admitted to the facility on [DATE] with diagnoses which includes non-pressure chronic ulcer of other part of left foot with necrosis of muscle and Methicillin Resistant Staphylococcus Aureus (MRSA) infection. R61's Physician Order Sheet printed on 8/16/23 showed R61 has an order for contact isolation precautions for MRSA wound left foot with a start date of 8/5/23. On 8/14/23 at 8:45 AM, V8 Registered Nurse stated R61 was on contact isolation due to having a MRSA infection of R61's left ankle/foot wound. V8 referred to the contact isolation sign and PPE cart next to doorway. On 8/15/23 at 2:10 PM, V6 Housekeeper was in R61's room cleaning without wearing a gown. On 8/16/23 at 8:45 AM, V5 Infection Control Preventionist stated staff entering a room with contact isolation need to wear the correct PPE when entering the room to provide care or clean the room. When cleaning an isolation room, the correct PPE needs to be worn even if the resident is not in the room when the cleaning is being performed. On 8/16/23 at 9:30 AM, V7 (3rd party housekeeping supervisor) stated when cleaning an isolation room, the housekeepers should wear the correct PPE for the type of isolation the resident is on. The facility's Infection Prevention and Control Policy revised on 6/1/23 showed A gown and gloves are necessary for all interactions in a contact isolation room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145699 If continuation sheet Page 12 of 12

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Citations

10 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0585GeneralS&S Dpotential for harm
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
0676GeneralS&S Dpotential for harm
F676 - Based on the comprehensive assessment of a resident and consistent with
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0760GeneralS&S Dpotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.

FAQ · About this visit

Common questions about this visit

What happened during the August 16, 2023 survey of The Pearl of Fox River Valley?

This was a inspection survey of The Pearl of Fox River Valley on August 16, 2023. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at The Pearl of Fox River Valley on August 16, 2023?

Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grie..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·August 16, 2023