The Pearl Of Fox River Valley

Penalties

• Jul 11, 2024 — Fine ($10,033)
• Jul 11, 2024 — IDPH fine (Nursing Home Care Act) ($25,000)
• Feb 14, 2024 — IDPH fine (Nursing Home Care Act) ($2,200)
• Nov 30, 2023 — IDPH fine (Nursing Home Care Act) ($25,000)
• Nov 22, 2023 — Fine ($132,415)

Inspection findings

1. Sep 4, 2025 Health · 9 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Sep 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Sep 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Sep 5, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Sep 5, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Sep 5, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Sep 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Sep 5, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0803 Nutrition and Dietary Deficiencies

     Ensure 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.

     Corrected Sep 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 5, 2025 · CMS health inspection

2. Nov 21, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Nov 27, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Nov 27, 2024 · CMS health inspection

3. Jul 11, 2024 Health · 10 findings
   • Not serious Scope/severity E

     F0585 Resident Rights Deficiencies

     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.

     Corrected Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jul 19, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0805 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

     Corrected Jul 19, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Aug 8, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jul 22, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jul 22, 2024 · CMS fire safety

   • Serious Scope/severity A

     Type A Illinois Nursing Home Care Act violation

     Type A: substantial probability of death or serious harm, or actual harm (1-129). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), and 300.1210d)6). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and 300.1210d)6).

     Statement of deficiencies (PDF)

4. Feb 14, 2024 IDPH docket NH 24-C0190 · 1 finding
   • Not serious Scope/severity B

     Type B Illinois Nursing Home Care Act violation

     Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.690b) and 300.690c). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.690.

     Statement of deficiencies (PDF)

5. Dec 16, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Dec 18, 2023 · CMS health inspection

6. Nov 30, 2023 Health · 4 findings
   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Dec 1, 2023 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Dec 1, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Dec 1, 2023 · CMS health inspection

   • Serious Scope/severity A

     Type A Illinois Nursing Home Care Act violation

     Type A: substantial probability of death or serious harm, or actual harm (1-129). Sections of the Illinois Administrative Code cited: 300.610a), 300.690b), 300.690c), 300.1210b) and 300.3240a). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.690, 300.1210b) and 300.3240a).

     Statement of deficiencies (PDF)

7. Nov 22, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0887 Infection Control Deficiencies

     Educate 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.

     Corrected Nov 23, 2023 · CMS health inspection

8. Aug 16, 2023 Health · 10 findings
   • Not serious Scope/severity D

     F0585 Resident Rights Deficiencies

     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.

     Corrected Aug 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0676 Quality of Life and Care Deficiencies

     Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

     Corrected Aug 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Aug 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Aug 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Aug 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Aug 17, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Aug 17, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 17, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Aug 29, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Oct 16, 2023 · CMS fire safety

9. Aug 5, 2022 Fire Safety · 10 findings
   • Not serious Scope/severity F

     E0015 Emergency Preparedness Deficiencies

     Address subsistence needs for staff and patients.

     Corrected Sep 2, 2022 · CMS fire safety

   • Not serious Scope/severity F

     E0022 Emergency Preparedness Deficiencies

     Establish policies and procedures for sheltering.

     Corrected Sep 2, 2022 · CMS fire safety

   • Not serious Scope/severity F

     E0041 Emergency Preparedness Deficiencies

     Implement emergency and standby power systems.

     Corrected Sep 2, 2022 · CMS fire safety

   • Not serious Scope/severity C

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Sep 2, 2022 · CMS fire safety

   • Not serious Scope/severity E

     K0271 Egress Deficiencies

     Have exits that are accessible at all times.

     Corrected Sep 2, 2022 · CMS fire safety

   • Not serious Scope/severity E

     K0281 Egress Deficiencies

     Install proper backup exit lighting.

     Corrected Sep 2, 2022 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 10, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Sep 2, 2022 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Sep 2, 2022 · CMS fire safety

   • Not serious Scope/severity E

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Sep 2, 2022 · CMS fire safety

Owners and managers (as published by CMS)

• AVELINO, JESSICA — adp of the snf, NOT APPLICABLE, since 08/02/2021
• AVELINO, JESSICA — operational/managerial control, NOT APPLICABLE, since 08/02/2021
• SHABAT, MENACHEM — operational/managerial control, NOT APPLICABLE, since 10/01/2018
• SHABAT, MENACHEM — managing control - governing body, NOT APPLICABLE, since 10/01/2018
• SHABAT, MENACHEM — adp of the snf, NOT APPLICABLE, since 10/01/2018
• SHAH, ASAD — adp of the snf, NOT APPLICABLE, since 10/01/2018
• SHAH, ASAD — operational/managerial control, NOT APPLICABLE, since 10/01/2018
• CIBC BANK USA — 5% or greater security interest, NOT APPLICABLE, since 10/01/2018
• CIBC BANK USA — operational/managerial control, NOT APPLICABLE, since 10/01/2018
• DOROS GENERATION TRUST U/A/D 1/3/12 — adp of the snf, NOT APPLICABLE, since 10/01/2018
• DOROS GENERATION TRUST U/A/D 1/3/12 — 5% or greater direct ownership interest, 43%, since 10/01/2018
• GPN FAMILY TRUST U/A/D 4/28/08 — adp of the snf, NOT APPLICABLE, since 10/01/2018
• GPN FAMILY TRUST U/A/D 4/28/08 — 5% or greater direct ownership interest, 43%, since 10/01/2018
• LARKIN AVE PROPERTY HOLDINGS, LLC — adp of the snf, NOT APPLICABLE, since 10/01/2018
• LARKIN AVE PROPERTY HOLDINGS, LLC — 5% or greater security interest, NOT APPLICABLE, since 10/01/2018
• LEGACY HEALTHCARE FINANCIAL SERVICES LLC — operational/managerial control, NOT APPLICABLE, since 10/01/2018
• LEGACY HEALTHCARE FINANCIAL SERVICES LLC — adp of the snf, NOT APPLICABLE, since 11/11/2025
• MILLER COOPER & CO, LTD — adp of the snf, NOT APPLICABLE, since 01/01/2024
• OAKWAY OPERATIONS LLC — 5% or greater direct ownership interest, 15%, since 10/01/2018