The Pearl of Fox River Valley
1950 Larkin Avenue, Elgin, IL 60123 · Kane County · 112 certified beds · avg 95 residents/day · certified since Jul 30, 1991
Part of chain: PEARL HEALTHCARE (15 facilities, chain avg rating 2.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Nov 30, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Dec 1, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 11, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 19, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 30, 2023 · F-0609 · triggered by a complaint
The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Why it matters: When incidents aren't reported promptly, abusers may continue harming residents and outside authorities can't step in.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 1, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (30)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Sep 4, 2025 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Sep 4, 2025 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 4, 2025 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Sep 4, 2025 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · from a complaint |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jul 11, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Dec 16, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Nov 30, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 30, 2023 | ▲ G · Actual harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Nov 30, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Nov 22, 2023 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. · from a complaint |
| Aug 16, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 16, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Aug 16, 2023 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Aug 16, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 16, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Aug 16, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Aug 16, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Aug 16, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 13 | 2 | J ▲ |
| 2024 | 8 | 1 | G ▲ |
| 2025 | 9 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $142,448.
| Date | Type | Amount / length |
|---|---|---|
| Jul 11, 2024 | Fine | $10,033 |
| Nov 22, 2023 | Fine | $132,415 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.78 | 2.99 | 3.95 | top 42% in Illinois; bottom 8% in the U.S. |
| Registered Nurse hours | 0.97 | 0.63 | 0.69 | top 14% in Illinois; top 17% in the U.S. |
| Weekend total nurse staffing | 2.58 | 2.67 | 3.50 | top 38% in Illinois; bottom 12% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.09 | 0.56 | 0.48 | top 8% in Illinois; top 5% in the U.S. |
| Total nursing staff turnover (%) | 48.5 | 44.5 | 45.8 | bottom 38% in Illinois; bottom 41% in the U.S. |
| RN turnover (%) | 37.9 | 41.8 | 42.9 | top 47% in Illinois; top 44% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.48, RN 1.21, weekend 3.23. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Doros Generation Trust U/A/D 1/3/12 | Organization | 5% or Greater Direct Ownership Interest | 43% | 10/01/2018 |
| GPN Family Trust U/A/D 4/28/08 | Organization | 5% or Greater Direct Ownership Interest | 43% | 10/01/2018 |
| Oakway Operations LLC | Organization | 5% or Greater Direct Ownership Interest | 15% | 10/01/2018 |
| Avelino, Jessica | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/02/2021 |
| Avelino, Jessica | Individual | ADP of the SNF | NOT APPLICABLE | 08/02/2021 |
| Cibc Bank USA | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 10/01/2018 |
| Cibc Bank USA | Organization | Operational/Managerial Control | NOT APPLICABLE | 10/01/2018 |
| Doros Generation Trust U/A/D 1/3/12 | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| GPN Family Trust U/A/D 4/28/08 | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Larkin Ave Property Holdings, LLC | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 10/01/2018 |
| Larkin Ave Property Holdings, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Legacy Healthcare Financial Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 10/01/2018 |
| Legacy Healthcare Financial Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/11/2025 |
| Miller Cooper & Co, LTD | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Shabat, Menachem | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/2018 |
| Shabat, Menachem | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2018 |
| Shabat, Menachem | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
| Shah, Asad | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2018 |
| Shah, Asad | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| River View Rehab Center | 0.5 mi | Elgin, IL | ★★☆☆☆ | 2/5 | abuse |
| Aperion Care Elgin | 0.8 mi | Elgin, IL | ★★★☆☆ | 3/5 | |
| Pearl of Elgin, the | 1.4 mi | Elgin, IL | ★★★★☆ | 3/5 | |
| Highland Oaks | 1.7 mi | Elgin, IL | ★★★★★ | 5/5 | |
| Crescent Care of Elgin | 2.1 mi | Elgin, IL | ★★★★☆ | 4/5 | |
| Tower Hill Healthcare Center | 2.6 mi | South Elgin, IL | ★☆☆☆☆ | 2/5 | abuse |
| Aperion Care Fox River | 2.6 mi | Elgin, IL | ★★★★★ | 5/5 | |
| South Elgin Living & Rehab Center | 2.8 mi | South Elgin, IL | ★★☆☆☆ | 2/5 | |
| Avondale Estates of Elgin | 3.3 mi | Elgin, IL | ★★★★★ | 5/5 | |
| Hearthwood SNF Senior Living | 7.2 mi | Bartlett, IL | ★★★★★ | 5/5 | |
| Alpine Care of St. Charles LLC | 7.5 mi | Saint Charles, IL | ★★★☆☆ | 3/5 | |
| Pearl of St Charles, the | 7.6 mi | St Charles, IL | ★☆☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 145699.