Pearl Of Orchard Valley
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
hospital for a change in condition. V9 could not remember if it was V10 (dayshift nurse) or V11 (Previous DON) that told him that about Resident R1's change of condition. On November 19, 2025, at 11:22 AM, V15 (LPN) said when there is an unwitnessed fall, she would do a head-to-toe assessment and she would also do the neuro checks (assessment) as per schedule (every 15 minutes x 4, every 30 minutes x2, .).On November 19, 2025, at 12:26 PM, V17 (LPN/Licensed Practical Nurse) said when there is an unwitnessed fall, he would first assess the resident by doing a head-to-toe assessment and then do a neuro assessment according to the schedule on the sheet (15 minutes x how many ever times.).On November 19, 2025, at 12:35 PM, V18 (LPN) said when a resident falls, we do a head-to-toe assessment, if they hit their head, we do a neuro assessment, and they are automatically sent out to the ER for evaluation. If we are not sure if
the resident hit their head, we start the neuro assessment and call the physician. Neuro assessments are documented on a paper form. V18 said she thinks they must chart on the resident for three days after the fall. Facility provided their 72-hour Neurological Flow Sheet. The form showed neuro checks are to be done every 15 minutes times 4, 30 minutes times 2, every hour times 6, and every 8 hours times 8.Facility provided their incident report for Resident R1. Facility started an investigation on September 19, 2025, for Resident R1's fall on September 11, 2025. The report was sent to IDPH (Illinois Department of Public Health). The final report was faxed to IDPH on September 24, 2025. The investigation showed neuro checks were initiated and completed. The supporting documents the facility presented did not include any documented neuro checks
after September 11, 2025. The investigation showed Resident R1 had a change in condition on September 18, 2025, but the progress note dated September 17, 2025, showed a nurse reached out the Nurse Practitioner due to increased fatigue and change in Resident R1's transfer and mobility status.Facility provided their policy, titled, Fall Prevention and Management dated October 29, 2021. The policy identified. #3 Procedure for Post-Fall Management. c. perform physical assessments including: i. head to toe assessment, ii. Vital signs, pulse, respiratory rate, pulse ox, blood pressure, and pain, iii. Range of motion, iv. Neurological Assessment as indicated.
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PEARL OF ORCHARD VALLEY in AURORA, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in AURORA, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PEARL OF ORCHARD VALLEY or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.