Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
The Pearl of Fox River Valley
ELGIN, IL · 112 certified beds · Last Life Safety survey July 11, 2024
CMS Certification Number 145699 · first certified July 1991
Ownership
Operated by PEARL HEALTHCARE · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IL
15 citations — more than 50% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (June 2025 to August 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was July 2024. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 15 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 15 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 5, 2022 | 10 |
| August 16, 2023 | 2 |
| July 11, 2024 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-07-11 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2024-07-11 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-07-11 |
| E-0022 | Establish policies and procedures for sheltering. | 1 | 2022-08-05 |
| K-0281 | Install proper backup exit lighting. | 1 | 2022-08-05 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2022-08-05 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2022-08-05 |
| E-0015 | Address subsistence needs for staff and patients. | 1 | 2022-08-05 |
What the citations cover
- Smoke Deficiencies 5
- Emergency Preparedness Deficiencies 3
- Egress Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Emergency Preparedness Deficiencies | 3 |
| Egress Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 11, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (August 8, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 22, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 22, 2024) |
August 16, 2023 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 29, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 16, 2023) |
August 5, 2022 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (September 2, 2022) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (September 2, 2022) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (April 10, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (September 2, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.