Pearl Of Orchard Valley
PEARL OF ORCHARD VALLEY in AURORA, IL — inspection on November 21, 2025.
Found 1 citation. 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
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 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 R1.
Facility started an investigation on September 19, 2025, for 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 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 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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