The Pearl of Fox River Valley

In the surveyor’s words

From the most serious findings on record at The Pearl of Fox River Valley, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 30, 2023

  Based on observation, interview and record review, the facility failed to ensure that R10 was free from physical, mental, and emotional abuse from an agency staff, V15 (CNA/Certified Nurse Assistant). The facility also failed to implement its policy to keep R10 free from further abuse. This failure resulted in Immediate Jeopardy on 11/5/2023 at 9:00 A.M., when R10 had sustained physical, emotional harm and mental distress from abusive care provided by V15. The facility also failed to implement their abuse policy by not reporting and investigating V15's inappropriate behavior such as yanking resident's bed rail, abrupt with care, ignoring call lights, that had occurred on 11/1/2023, and this had led to physical abuse on 11/5/2023 when V15 jerked R10's arm. […]

• Immediate jeopardy, isolatedF689Apr 20, 2023

  Based on observation, interview and record review, the facility failed to supervise residents with wandering and elopement risks. The facility also failed to provide adequate supervision to prevent elopement from the facility. The facility failed to ensure all facility's exit door alarm systems (9 exit doors) were maintained in functioning order to alert staff and able to respond to residents exiting the facility. The facility also failed to follow its elopement policy by not determining the cause of the triggered alarms, failing to monitor safety alarm systems to ensure they function, and assessing residents for risk of elopement behavior. […]

• Actual harm, isolatedF689Jul 11, 2024

  Based on observation, interview and record review, the facility failed to ensure safe transport of resident to the shower room when a shower chair was utilized for the transfer in place of a wheelchair. This failure resulted in R24 falling from the chair and fracturing both of her legs. This applies to 1 of 4 residents (R24) reviewed for accidents in the sample of 26. The findings include: R24 is a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that include Multiple Sclerosis, Chronic pain, and Polyneuropathy. […]

• Actual harm, isolatedF609Nov 30, 2023

  Based on observation, interview and record review, the facility failed to implement their abuse policy regarding immediate reporting and investigation of an alleged abuse. The delay in reporting and investigating meant that V15(CNA/Certified Nursing Assistant) staff continued to work after R10 made allegation of inappropriate behavior, yanking R10's bed rail and was abrupt with care. This failure resulted in R10 sustaining bruises, emotional harm and mental distress from abusive care provided by V15. This applies to one of three residents (R10) reviewed for injuries of unknown origin and abuse. The findings include: The EMR (Electronic Medical Record) showed that R10, an [AGE] year-old, was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF692May 3, 2023

  Based on observation, interview, and record review, the facility failed to follow their policy to assess and address significant weight losses in residents, failed to notify the physician and resident representative of significant weight loss, and failed to implement interventions to prevent future weight loss. This failure resulted in R1 and R4 experiencing significant weight loss. This applies to 2 of 3 residents (R1, R3) reviewed for improper nursing in the area of weight loss in the sample of 5. The findings include: 1. On April 26, 2023 at 3:44 PM, R1 was lying in bed. R1 was not able to answer questions due to her cognitive status. On April 27, 2023 at 9:15 AM, R1 was sitting up in her bed. Her breakfast tray was sitting on top of her bedside table. […]