Report
TheVardellReport
The Pearl of Fox River Valley
Skilled nursing facility and nursing facility
1950 Larkin Avenue
Elgin, IL 60123
Report
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The Vardell Report.The Pearl of Fox River Valley
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Elgin, IL
- Record Period
- 2023–2025
- Source Documents
- 9
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 7 inspections from August 2023 to September 2025, state surveyors documented 30 findings at The Pearl of Fox River Valley; 30 have a recorded correction; CMS lists 2 enforcement actions in the window.
- Inspections
- 7
- 2023–2025, standard and complaint
- Findings
- 30
- Deficiencies cited by state inspectors
- Corrected
- 30
- Of 30 findings, with a recorded correction date
- Penalties
- 2
- 2 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 4 | 13 | 2 |
| 2024 | 2 | 8 | 1 |
| 2025 | 1 | 9 | 0 |
| 2026 | 0 | 0 | 0 |
What the Record Shows
- 30 of 30 findings have a recorded correction date.
- CMS lists 2 enforcement actions in the window: 2 fines totaling $142,448, their payment not published.
- 5 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, September 4, 2025, recorded 9 findings (most serious: Level E).
What to Ask About
- Quality of Care, Cited in Three Inspections
- Pressure Injury Care, Cited in Three Inspections
- Grievances, Cited in Two Inspections
- Accident Hazards and Supervision, Cited in Two Inspections
- Continence and Catheter Care, Cited in Two Inspections
- Significant Medication Errors, Cited in Two Inspections
- Infection Control, Cited in Two Inspections
Report at a Glance
- Facility
- The Pearl of Fox River Valley
- Address
- 1950 Larkin Avenue, Elgin, IL 60123
- CMS Certification Number
- 145699
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 112
- Ownership
- For profit - Limited Liability company
- Record Window
- August 16, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2025
Standard health inspection
9 findings
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Sep 5, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Sep 5, 2025
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level ENo actual harm, potential for moreCorrected Sep 5, 2025
- F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level ENo actual harm, potential for moreCorrected Sep 5, 2025
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Sep 5, 2025
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Sep 5, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 5, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Sep 5, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Sep 5, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Nov 27, 2024
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Nov 27, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
6 findings
The same visit included a complaint investigation.
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jul 19, 2024
- F585Honor 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.Level ENo actual harm, potential for moreCorrected Jul 19, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jul 19, 2024
- F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level ENo actual harm, potential for moreCorrected Jul 19, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jul 19, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Jul 19, 2024
Enforcement Action
Civil money penalty, $10,033 imposed July 11, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 11, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
1 finding
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 18, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
3 findings
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level JImmediate jeopardyCorrected Dec 1, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level GActual harmCorrected Dec 1, 2023
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Dec 1, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
1 finding
- F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Level DNo actual harm, potential for moreCorrected Nov 23, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
8 findings
- F761Ensure 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.Level ENo actual harm, potential for moreCorrected Aug 17, 2023
- F585Honor 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.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Aug 17, 2023
Enforcement Action
Civil money penalty, $132,415 imposed November 22, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 16, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Quality of Care, Cited in Three Inspections
Inspectors cited F684 in August 2023, July 2024 and September 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232323242425F684 across all 7 inspections, oldest to newest - 2
Pressure Injury Care, Cited in Three Inspections
Inspectors cited F686 in August 2023, July 2024 and September 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232323242425F686 across all 7 inspections, oldest to newest - 3
Grievances, Cited in Two Inspections
Inspectors cited F585 in August 2023 and July 2024. This citation covers residents’ right to voice grievances without reprisal, and the home’s process for resolving them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232323242425F585 across all 7 inspections, oldest to newest - 4
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in July 2024 and September 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232323242425F689 across all 7 inspections, oldest to newest - 5
Continence and Catheter Care, Cited in Two Inspections
Inspectors cited F690 in July 2024 and September 2025. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232323242425F690 across all 7 inspections, oldest to newest - 6
Significant Medication Errors, Cited in Two Inspections
Inspectors cited F760 in August 2023 and November 2024. This citation covers whether residents are free from significant medication errors. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232323242425F760 across all 7 inspections, oldest to newest - 7
Infection Control, Cited in Two Inspections
Inspectors cited F880 in August 2023 and September 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
23232323242425F880 across all 7 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in three inspections, most seriously at level E.
- 02
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in three inspections, most seriously at level E.
- 03
How do we file a grievance, who answers it, and how quickly?
Grievances: cited in two inspections, most seriously at level E.
- 04
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level G.
- 05
How is continence care scheduled, and how do you prevent urinary infections?
Continence and Catheter Care: cited in two inspections, most seriously at level E.
- 06
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in two inspections, most seriously at level D.
- 07
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level D.
- 08
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 09
What led to the 2024 fine, and has it been paid?
A $10,033 civil money penalty was imposed July 11, 2024. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Illinois state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Aug 16, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Nov 22, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Nov 30, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Dec 16, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Jul 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Nov 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Sep 4, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 145699
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowAugust 16, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before August 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.