Pearl Of Orchard Valley
PEARL OF ORCHARD VALLEY in AURORA, IL — inspection on September 18, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
x 4 weeks to ensure that residents are monitored for inappropriate sexual behaviors and wandering.
jeopardy to resident health or Administrator and/or designee will conduct video surveillance review twice a day x 4 weeks to safety observe for any inappropriate wandering behaviors.
Start: September 18, 2025; goal: October 16, 2025.d.
Any quality assurance issue/s and progress will be reported to facility's monthly QAPI
the facility stay in compliance and if concerns are identified the Quality Assurance Committee will add on additional months until Compliance is sustained.e.
Administrator and/or Director of Nursing will complete monthly in-servicing on the facility's sexual abuse policy and sexual behavior management for three months and quarterly thereafter.
Start: October 1, 2025.Date of Completion: September 18, 2025
145473 09/18/2025
Pearl of Orchard Valley 2330 West Galena Boulevard Aurora, IL 60506
authorities.
interview and record review, the facility failed to timely report allegations of sexual and verbal abuse
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).
The EMR shows that R2 is a [AGE] year-old male admitted [DATE], with diagnoses including dementia, bipolar disorder, alcoholic cirrhosis, and adjustment disorder.
The MDS dated [DATE], indicates cognitive intactness (BIMS 14/15), and a history of inappropriate behaviors such as wandering and entering other residents' room.
The incident detail showed that on August 29, 2025, at 11:30 AM, an incident involving R2 exposing his genitals to R1 in R1's room was observed. R2 was alone in R1's room for approximately 8 minutes with the door closed, as confirmed by video surveillance footage. R2 was seen exiting R1's room with sweatpants still not fully pulled up.On September 9, 2025 at 12:12 P.M., V4 (Restorative Aide) said she entered R1's room at approximately 10:54 AM on August 29,2025 and observed R2 standing by R1's head, with pants lowered to the knees and buttocks exposed, while R1 was lying sideways, facing R2.The incident report showed the sexual abuse allegation was identified on August 29, 2025, R1's POA was notified 7 days later, on September 4, 2025.; IDPH was notified on September 4, 2025, a 6 -day delay; local police were not notified until 10 days after the incident. On September 10, 2025 at 1:10 P.M., V16 (R1's Family/POA) expressed dissatisfaction regarding the delay, stating that potential evidence was lost. On September 10, 2025 at 2:31 P.M., V18 (Hospice Physician) had confirmed that neither him nor his alternate physician were not notified. V18 added that if they would have been notified timely, an appropriate evaluations or treatments could have been initiated. On September 22, 2025 at 2:59 P.M., V22 (Primary Physician) had validated that neither him or his alternate was not informed and stated appropriate evaluations or treatments could have been initiated had they been notified timely.On September 9, 2025 at 3:30 P.M., V1 (Administrator) explained that the delay of reporting was he was new. 2, The EMR shows that R3, is an [AGE] year-old, and was admitted to the facility on [DATE]. R3's diagnoses included unspecified dementia, major depressive disorder, PVD (peripheral vascular disease) and localized swelling.
The MDS dated [DATE] showed that R3's cognition was moderately impaired and that she required substantial assistance from staff for ADLs (Activities of Daily Living).
The EMR shows that R4, a [AGE] year-old admitted to the facility on [DATE]. R4's diagnoses included unspecified dementia, anxiety disorder and diabetes mellitus.
The MDS dated [DATE] showed that R4 is moderately impaired in cognition and required supervision with ADLs.
The facility's abuse allegation report showed that there was a verbal altercation between R3 and R4 on August 29, 2025.
The abuse allegation report showed that R3 had sustained a skin tear and was bleeding from her lower leg.
The bleeding was a skin tear was sustained and hit her leg, when R3 was startled from R4's shouting to R3.
This abuse investigation was reported to IDPH on September 4, 2025, which was 6 days after the verbal abuse allegation was identified. V1 had the same response as to the reason of delayed reporting.
The facility's Abuse Prevention Policy (dated October 24, 2022) states: The Administrator or designee shall notify the resident's representative, the physician, and shall notify the local police department of any suspicion of criminal activity immediately.
145473 09/18/2025
Pearl of Orchard Valley 2330 West Galena Boulevard Aurora, IL 60506
Review of the progress notes
physical contact when R2 was found with exposed genitals.
This includes R1's condition of her face, any redness, irritation, condition of hair if it was messy, tangled, disordered, or rumpled.
The environmental condition if there were any wet spots on R1's head of bed.
The facility's investigation included interviews with staff on duty and residents who have expressed no awareness of abuse investigation.
There were no other interviews that would show possible cause why R2 ended in R1's room.
The facility did not review R2's wandering behavior.
The facility failed to review the video surveillance footage as part of the investigation.
The facility concluded that sexual abuse was not substantiate since, there was no inappropriate contact .
The Electronic Medical Record (EMR) shows R1 is a [AGE] year-old female resident admitted to the facility on [DATE]. R1 has multiple diagnoses including dementia, cerebral atherosclerosis, unspecified psychosis, psychotic disorder, anxiety disorder and a recipient of hospice care.
The most recent Minimum Data Set (MDS) dated [DATE] shows R1 has severe cognitive impairment, not able to recall her location, person, and place. R1 also showed no signs of psychosis including hallucination, delusion, and no negative behavior such as rejection of care and wandering. R1 is dependent on facility staff for ADLs (Activities of Daily Living).
On September 9, 2025 at 12:15 P.M., R1 was observed in the secured dementia unit' dining room. V7 (CNA/Certified Nurse Assistant) was feeding R1 for lunch. R1 was confused and not able to carry a conversation, and not able to verbalize needs. V7 said that R1 was totally dependent from staff with all aspects of ADLs (Activities of Daily Living). V7 also said that R1 was not able to verbalize her needs and just utter incoherent words.
The Electronic Medical Record (EMR) shows R2 is a [AGE] year-old male resident admitted to the facility on [DATE]. R2 has multiple diagnoses including unspecified dementia, bipolar disorder, alcoholic cirrhosis, alcohol abuse with intoxication, hepatic encephalopathy, malignant neoplasm of right kidney, and adjustment disorder.
The most recent Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively intact with BIMS (Brief Interview Mental Status) score of 14/15. R2's temporal orientation shows he can recall correct month and year, able to correctly repeated words with no cues required for the words repetition.
The assessment also showed that R2 had no signs of delirium, inattention, disorganized thinking, and no altered level of consciousness.
The mood assessment showed R2 was feeling down, depressed, trouble falling asleep, and feeling tired. R2 was assessed with no indicators of psychosis including hallucination, delusion, and misconception of belief. R2 was identified with behavioral symptoms such as exhibited physically pacing, rummaging, public sexual acts, disrobing in public and wandering that occurred 1-3 days in a period of 7 days. R2 has no impairment for upper and lower extremities, is ambulatory, and required only set up, and supervision for ADLs. On September 9, 2025 at 12:35 P.M., R2 was observed in the dining eating his lunch. R2 was aware of his location, his name and reason why he was at the facility. R2 said he was admitted to the facility after a hospitalization due to his kidney and liver condition.
However, when surveyor asked regarding his wandering and what was he doing entering other residents' room he replied nothing.
The facility's abuse policy dated October 24, 2022 showed that Residents have the right to be free from abuse.
Abuse means any physical or mental or sexual assault inflicted upon resident other than by accidental means. sexual abuse in non-consensual contact of any type with a resident.
The facility prohibits abuse, neglect, exploitation of its residents including verbal, mental, sexual abuse.For investigation: As soon as possible, after the allegation of abuse, the administrator or designee will initiate an investigation into the allegation . investigation includes a review of all circumstances surrounding the incident.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.