9 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Elgin, IL
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2355 Royal Boulevard, Elgin, IL
(847) 888-9585
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
139
Certified beds
Average residents
127
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pearl Healthcare
Operator or chain grouping
Approved since
1994-12-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.77
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.27
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.83
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
2.78
CMS adjusted total nurse staffing hours
Case-mix index
1.61
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
11,124
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.28
Baseline 17.99% · Performance 20.38% · Measure score 2.28 · Achievement 2.28 · Improvement 0
Healthcare-associated infections
1.97
Baseline 8.22% · Performance 7.42% · Measure score 1.97 · Achievement 1.38 · Improvement 1.97
Total nurse turnover
2.92
Performance 51.72% · Measure score 2.92 · Achievement 2.92 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 2.69 hours · Performance 2.68 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.78% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 178 · Observed rate 12.36% · Lower 95% interval 7.45% |
| Discharge to community | 52.93% |
50.57%
2.4 pts better
|
No Different than the National Rate · Eligible stays 152 · Observed rate 46.05% · Lower 95% interval 43.95% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 116 · Denominator 116 |
| Falls with major injury | 0.86% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 116 |
| Discharge self-care score | 56.79% |
53.69%
3.1 pts better
|
Numerator 46 · Denominator 81 |
| Discharge mobility score | 51.85% |
50.94%
0.9 pts better
|
Numerator 42 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 116 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.42% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 8.54% · Lower 95% interval 4.39% |
| Staff COVID-19 vaccination coverage | 4.55% |
8.2%
3.6 pts worse
|
Numerator 8 · Denominator 176 |
| Staff flu vaccination coverage | 65.41% |
42%
23.4 pts better
|
Numerator 121 · Denominator 185 |
| Discharge function score | 64.2% |
56.45%
7.8 pts better
|
Numerator 52 · Denominator 81 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 42 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 19.44% |
25.2%
5.8 pts worse
|
Numerator 14 · Denominator 72 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.0
0.7 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.3
1.6 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
89.6%
9 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 99.0% · Q3 99.0% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.7% |
91.6%
1.1 pts better
|
95.5%
2.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.0% · Q3 3.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 57.4% |
50.3%
7.1 pts worse
|
11.4%
46 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.6% · Q2 41.3% · Q3 62.2% · Q4 59.6% · 4Q avg 57.4% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
6.5%
4.5 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.1% · Q3 1.1% · Q4 2.1% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.6% |
18.5%
1.9 pts better
|
19.6%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.7% · Q3 15.9% · Q4 19.2% · 4Q avg 16.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
22.8%
8 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 9.8% · Q3 18.1% · Q4 18.1% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.0% |
17.2%
4.2 pts better
|
16.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 18.8% · Q3 7.9% · Q4 19.4% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
15.0%
8.7 pts better
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.8% · Q3 5.0% · Q4 13.0% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.1%
0.6 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.0% · Q3 1.7% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.7%
0.7 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 1.8% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
21.3%
2.3 pts better
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 19.8% · Q3 15.8% · Q4 17.4% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.2%
2.6 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.9% · Q3 3.4% · Q4 2.6% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.4% |
68.8%
13.6 pts better
|
81.7%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 67.8% · Q2 77.8% · Q3 86.9% · Q4 96.0% · 4Q avg 82.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
14.0%
2.2 pts better
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 12.4% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
2.3%
1 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.9% |
63.0%
6.1 pts worse
|
79.7%
22.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.5% |
26.2%
4.7 pts better
|
23.9%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.5% · Observed 21.9% · Expected 24.3% · Used in QM five-star |
Survey summary
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Nutrition and Dietary (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Nutrition and Dietary (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-13
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-13
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-13
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-13
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-13
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-09-13
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-26
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-26
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-09-26
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-26
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-12-16
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-12-16
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-16
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-16
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2022-12-16
Inspection history
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2025-09-09
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-10-30
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-07
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-09-07
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-09-07
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-09-07
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-07
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-07
Health
Provide or obtain dental services for each resident.
Corrected 2024-09-18
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-09-26
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-09-26
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-09-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-26
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-09-26
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-26
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-09-26
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-09-26
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-26
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-09-26
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-26
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-26
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-26
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-09-26
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-26
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-03-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-09
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-09
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-11-09
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-11-09
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2022-11-09
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-11-09
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-11-09
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-11-09
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-11-09
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-09
Penalties and ownership
Payment Denial · denial start 2025-08-19 · 44 days
44 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Security Interest · Organization
5% Or Greater Security Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
Contracted Managing Employee · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Nearby options
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