Pearl of Orchard Valley

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the use of the appropriate total mechanical lift device and the required two-person assistance when obtaining a resident's weight and performing transfers for one resident (R1) who was totally dependent on staff for transfers. This failure resulted in R1 sustaining a traumatic fracture of the right tibia and fibula after falling during an improper transfer. This applies to 1 of 3 sampled residents (R1) reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the physician-ordered plan of care and follow interventions intended to prevent and manage constipation for a resident with declining renal function and Stage IV chronic kidney disease. The facility failed to ensure the resident received appropriate assessments, dietary interventions, and as-needed constipation treatments despite documented evidence of ongoing bowel elimination concerns. This applies to 1 of 4 residents (R4) reviewed for bowel elimination.

Inspectors wroteBased on observation, interview, record review, the facility failed to provide catheter care in accordance with accepted standards of practice by failing to cleanse the urethral meatus during indwelling urinary catheter care. The facility also failed to follow a physician's order to change an indwelling urinary catheter when a urinary tract infection (UTI) occurred. This applies to 2 of 3 residents (R1 and R3) reviewed for indwelling urinary catheter care.

Inspectors wroteBased on interview and record review, the facility failed to employe a full time qualified Food Service Manager/Director to manage resident food and nutrition service operations at the facility. This applies to all 119 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide palatable meals at acceptable service temperatures per facility policy. This applies to all 116 residents receiving oral diets in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their water management plan for Legionella. The facility also failed to follow their policy for EBP (Enhanced Barrier Precautions). This applies to all 119 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide positioning assistance and grooming/hygiene for residents who required assistance for ADL (Activities of Daily Living) care. This applies to 4 of 6 residents (R63, R69, R82, R140) reviewed for ADL care in the sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to offer and administer influenza and pneumococcal vaccines to residents. The facility also failed to follow their policy to document residents' immunization status in the medical record. This applies to 5 of 5 residents (R11, R35, R66, R79, and R90) reviewed for immunizations in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a wheelchair to accommodate a resident's assessed needs. This applies to 1 of 1 resident (R140) reviewed for accommodation of needs in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that accepted standards of quality care and safe medication administration practices were followed during medication administration. This applies to 1 of 6 residents (R62) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use of adaptive devices for residents with contracted hands to prevent further decline in range of motion and promote comfort related to contractures. This applies to 2 of 4 residents (R63 and R140) reviewed for contractures in a sample of 25 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure that medication regimen recommendations were addressed by the physician in a timely manner. This failure applies to 1 of 5 residents (R79) reviewed for medication regimen review in a sample of 25

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from unnecessary medications. This applies to 1 of 2 residents (R1) reviewed for antibiotic use in the sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for Antibiotic Stewardship. This applies to 1 of 2 residents (R1) reviewed for antibiotic use in the sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to offer the 2025-2026 COVID-19 immunization to residents. This applies to 3 of 5 residents (R66, R79, and R90) reviewed for immunizations in the sample of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain facility roof, kitchen ceiling, and kitchen flooring in good repair per facility policy. This applies to all 119 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to keep residents free from sexual abuse when R3 sucked on R2's breast. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on February 9, 2026, at 11:30 AM, when R2, a female dementia resident with known inappropriate sexual behaviors was left unsupervised in the dining room with R3, a male dementia resident, and R2 waved R3 over, lifted her shirt, and R3 sucked on R2's breast. This applies to 2 of 4 residents (R2 and R3) reviewed for sexual abuse in the sample of 6. V3 (Assistant Administrator), V17 (Senior Administrator), and V18 (Regional Nurse Consultant) were notified of the Immediate Jeopardy on March 10, 2026, at 11:47 AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for notification of resident's change in condition. This applies to 1of 3 residents (R1) reviewed for falls in the sample of 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow fall prevention interventions for a resident who was a known fall risk. This applies to 1of 3 residents (R1) reviewed for falls in the sample of 6.

Inspectors wroteBased on interview, and record review, the facility failed to assess a resident after an unwitnessed fall. This failure resulted in a delay of treatment for R1 who sustained subdural hematoma after a fall incident. This applies to 1 of 3 residents (R1) reviewed for assessments in the sample of 3.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the safety and protection of R1, a female resident with severe cognitive impairment, from R2, a male resident with a documented history of wandering and entering other residents' rooms within the secured dementia care unit. This failure resulted in an incident on August 29, 2025, in which R2 entered R1's room without staff awareness. R2 had remained in the room with the door closed for approximately eight minutes. Staff later discovered R2 near R1, with his genitals exposed and near R1's face. This incident was a significant breakdown in supervision necessary to protect vulnerable residents from harm including sexual abuse. This applies to 1 of 2 residents (R1) reviewed for abuse, from a total sample of 11 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to timely report allegations of sexual and verbal abuse to the residents' Power of Attorney (POA), physician, the Illinois Department of Public Health (IDPH), and the local police department in accordance with the facility's abuse policy. This applies to 2 of 4 residents (R1, R3) reviewed for abuse in the sample of 11. The findings Include: 1. The EMR (Electronic Medical Record) shows that R1 is a [AGE] year-old female, admitted [DATE], with diagnoses including dementia, cerebral atherosclerosis, unspecified psychosis, anxiety disorder, and is under hospice care. The Minimum Data Set (MDS) dated [DATE], indicates R1 has severe cognitive impairment and requires total assistance for Activities of Daily Living (ADLs). [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a comprehensive investigation into an allegation of sexual abuse. As a result, the facility prematurely concluded the allegation to be unsubstantiated without completing all required investigative steps. This applies to 1 of 2 residents (R1 and R2) reviewed for sexual abuse allegations in a sample of 11 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was treated in a dignified manner for 1 of 7 residents (R1) reviewed for dignity in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to document and obtain treatment orders for a resident at risk for skin breakdown who had complaints of redness and burning to her buttock area for 1 of 7 residents (R1) reviewed for quality of care in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor a resident's skin for breakdown. This failure resulted in a pressure injury not being identified until it was a stage 3, which delayed treatment, and the wound became infected. The facility also failed to implement pressure ulcer care plan interventions. This applies to 1 of 3 residents (R108) reviewed for pressure injury in a sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 132 residents in the facility receiving dietary services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents who require assistance with their ADLs (Activities of Daily Living). This applies to 5 out of 5 (R71, R90, R117, R109, and R19) residents reviewed for ADLs in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for smokers, and failed to properly assess residents for safe smoking. This applies to 5 out of 5 (R28, R50, R75, R95, R116) residents reviewed for safe smoking in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for medications brought from home and failed to secure resident medications in a locked compartment. This applies to 4 of 4 residents (R54, R78, R86, R195) reviewed for medications in a sample of 32.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's right to be free from physical abuse. This applies to 2 of 3 residents (R67 and R124) reviewed for abuse in a sample of 32.

Inspectors wroteBased on interview and record review the facility failed to submit reports of abuse to the Illinois Department of Public Health within the mandated timeframes. This applies to 1 of 3 residents(R36) reviewed for abuse in a sample of 32.

Inspectors wroteBased on interview and record review the facility failed to immediately initiate an investigation into allegations of abuse to assure the wellbeing of a resident. This applies to 1 of 3 residents(R124) reviewed for abuse in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative services to residents with contractures. This applies to 2 out of 3 (R71 and R90) residents reviewed for contractures in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide catheter care to residents. This applies to 2 out of 2 (R90, R54) residents reviewed for urinary care in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean and empty a resident's ostomy bag. This applies to 1 of 1 resident (R19) reviewed for ostomies in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer tube feedings and care for enteral tubes as ordered for residents with gastrostomy tubes (g-tubes). This applies to 2 out of 3 (R117 and R5) residents reviewed for gastrostomy tubes in a sample of 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered. There were 30 opportunities with 2 errors resulting in a 6.6% error rate. This applies to 2 of 3 (R134, R342) residents observed in the medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve a resident his prescribed diet. This applies to 1 out of 3 (R71) residents reviewed for diets in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent a resident from acquiring a pressure ulcer. This failure resulted in R2 developing a stage 2 pressure ulcer on the left ischium. This applies to 1 of 3 residents (R2) reviewed for pressure ulcers in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care to a resident. This applies to 1 of 3 residents (R2) reviewed for timely incontinence care in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to ensure a staff member was skilled to change an indwelling pleural catheter dressing appropriately for a resident with respiratory conditions. This applies to 1 out of 4 residents (R2) reviewed for nursing care services.

Inspectors wroteBased on interview and record review the facility failed to document the assessment of a resident (R2) who had a change in condition and required a transfer to the hospital for abnormal vital signs. This applies to 1 out of 4 residents (R2) reviewed for nursing care services.

Inspectors wroteBased on interview and record review the facility failed to ensure a care plan conference that included the resident, resident representative and interdisciplinary team was performed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 2 of 3 residents (R1 and R3) reviewed for comprehensive care plans in the sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needs extensive assistance getting to the toilet was brought to the toilet in a timely manner for 1 of 4 residents (R2) reviewed for activities of daily living (ADLs) in the sample of 4.

Inspectors wroteBased on observation, interview, and record review that facility failed to ensure pressure ulcer treatment interventions were in place for 2 of 3 residents (R1 and R2) reviewed for pressure ulcers in the sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide supervision and safe eating interventions for residents with swallowing and eating disorders. This applies to 2 of 4 residents (R1, R2) reviewed for weight loss and nutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nutritional supplements as ordered for residents with weight loss and nutritional needs. This applies to 2 of 4 residents (R2, R8) reviewed for nutrition and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to successfully notify the physician of a significant change in condition in a timely manner and failed to notify administration when the physician's answering service did not respond. As a result of this failure, there was a delay in obtaining treatment and pain relief for R1 for 2 days after swelling and pain was noted. R1's radiology revealed a supracondylar fracture with anterior angulation of the fracture site and a supracondylar fracture of the distal femur with anterior angulation at the fracture site. This applies to 1 of 3 residents (R1) reviewed for pain and injuries of unknown origin.

Inspectors wroteBased on interview and record review, the facility failed to utilize a gait belt when transferring a resident and failed to revise R1's plan of care after an earlier fall incident. This applies to 1 of 3 residents (R1) reviewed for fall and injuries.

Inspectors wroteBased on interview and record review, the facility failed to have a designated certified IP (Infection Preventionist) who was responsible for the facility's Infection Control Prevention Program. This applies to all 130 residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement its Infection Prevention and Control Program when it failed to provide surveillance data to the Local Health Department that identified other residents at risk for Legionnaire's disease after a confirmed case of Legionnaires' disease was associated with the facility. The facility also failed to identify R1's Legionnaire's diagnosis when he returned from the hospital and failed to notify R1's care team of the diagnosis. This applies to 8 of 8 residents (R1-R8) reviewed for communicable disease of Legionnaire's.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and provide pain medication for a resident who is in pain. In addition, the facility failed to reassess if the pain medication that was provided was effective. This failure resulted to R97 and R98 to experience severe pain and resulted in R97's inability to complete activities during her physical therapy session. This applies to 2 of 3 (R97 and R98) reviewed for pain management in a sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility had provided sufficient staffing to meet the care needs of residents of the facility. This has the potential to affect all 131 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide palatable meals to facility residents. This applies to all 128 residents receiving oral diets in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to sanitize pots/pans utilizing a sanitizing solution at a concentration per manufacturer instructions, failed to change gloves and wash hands after touching soiled surfaces during food preparation., and failed to store resident food per facility policy. This applies to all 128 residents residing in the facility receiving oral diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming and timely toileting hygiene for residents who require assistance with activities of daily living (ADL) care. This applies to 12 of 13 residents (R115, R222, R29, R38, R70, R77, R1, R324, R328, R98, R97, and R122) reviewed for ADL (Activities of Daily Living) in the sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve the facility menu as planned. This applies to 10 of 10 residents (R25, R46, R52, R91, R100, R106, R323, R325, R326, R327) reviewed for menus not followed in a sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare pureed diets as per facility policy. This applies to 10 of 10 residents (R8, R22, R23, R28, R33, R34, R41, R72, R91, and R110) reviewed for pureed diets.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable standards for infection control by not implementing hand hygiene, and use of PPE (personal protective equipment) during direct resident care. The facility also failed to ensure that an indwelling catheter drainage bag was stored in a manner to prevent urine infection. This applies to 6 of 7 residents (R43, R63, R70, R97, R122 and R222) in a sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to honor resident religious food preferences. This applies to 2 of 4 residents (R323 and R325) reviewed for religious food preferences in a sample of 29.

Inspectors wroteBased on interview and record review, the facility failed to provide restorative rehabilitation services to a resident as recommended by physical therapy recommendations. This applies to 1 of 1 resident (R46) reviewed for restorative services in a sample of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and provide adaptive device to residents, to prevent further reduction in ROM (range of motion). This applies to 3 of 4 residents (R14, R41 and R122) reviewed for range of motion in the sample of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the physician's order to check for residual feeding before administration of the enteral feeding and failed to check for proper placement of the feeding tube per policy and procedure. The facility also failed to ensure that the head of the resident's bed was elevated while receiving enteral feeding. This applies to 2 of 2 residents (R63 and R122) reviewed for feeding tube in the sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications as ordered by the physician. There were 25 opportunities with 3 errors, resulting in 12% medication error rate. This applies to 2 of 5 residents (R63 and R99) observed during medication pass in the sample of 29.

Inspectors wroteBased on observation and interview, the facility failed to post the required information for contacting the State Survey Agency Complaint Hotline to make it available to all residents and their families. This affects all 133 residents residing in the facility.

Inspectors wroteBased on observation and interview, the required Survey Results folder did not contain the results of the survey of 9/29/2023 and the Survey Results folder was not accessible to all residents in the facility. This affects all 133 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to post the facility the required information regarding daily Nurse staffing in the facility. This affects all 133 residents residing in the facility.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide privacy during incontinence care. This applies to 1 of 5 residents (R2) reviewed for privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services regarding a resident's excoriated sacral areas and follow their plan of care to protect and maintain skin integrity, promote wound healing, and prevent wound infection. This failure resulted in the development of a newly opened wound on R3's right upper thigh, and R2's excoriated sacral areas with active bleeding and was contaminated with urine-soaked incontinence brief. This applies to two of three residents (R2 and R3) reviewed for skin alteration.

Inspectors wroteBased on observation, interview and record review the facility failed to monitor, identify, and provide specific care interventions for pressure ulcer prevention and treatment for two (R1 and R2) of three residents reviewed for pressure ulcers from a sample of 11. This failure resulted in R1's developing a new pressure ulcer categorized at an advance stage 3 pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility had provided sufficient staffing to meet the care needs of residents of the facility. This failure resulted in R3's newly open wound to the right upper thigh and R2's active bleeding from skin excoriation from the sacral area. This failure has the potential to affect all 106 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the facility's policy for infection control regarding the use of PPE (Personal Protective Equipment), hand hygiene and disinfecting environmental surfaces to contain spread of Covid-19 outbreak. This has the potential to affect all 106 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received ADL (Activities of Daily Living) assistance per their plan of care. This applies to 11 of 11 residents (R1 through R11) reviewed for ADLs in a sample of 11.