All citations for The Pearl of Downers Grove

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to The Pearl of Downers Grove

Last standard health inspection on record

April 14, 2025

Showing 1 to 25 of 86 citations

  1. Harm to a resident

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Isolated (one or a few residents). CMS level G.

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 30, 2025).

  2. Harm to a resident

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Isolated (one or a few residents). CMS level G.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 30, 2025).

  3. Harm to a resident

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Isolated (one or a few residents). CMS level G.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of May 4, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (May 8, 2024).

  4. No harm, with potential for more than minimal harm

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

    Widespread (many residents). CMS level F.

    Health citation F-0623, Resident Rights Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 30, 2025).

  5. No harm, with potential for more than minimal harm

    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

    Widespread (many residents). CMS level F.

    Health citation F-0625, Resident Rights Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 30, 2025).

  6. No harm, with potential for more than minimal harm

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

    Widespread (many residents). CMS level F.

    Health citation F-0725, Nursing and Physician Services Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 30, 2025).

  7. No harm, with potential for more than minimal harm

    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

    Widespread (many residents). CMS level F.

    Health citation F-0801, Nutrition and Dietary Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 30, 2025).

  8. No harm, with potential for more than minimal harm

    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.

    Widespread (many residents). CMS level F.

    Health citation F-0803, Nutrition and Dietary Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 30, 2025).

  9. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Widespread (many residents). CMS level F.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 30, 2025).

  10. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Widespread (many residents). CMS level F.

    Health citation F-0880, Infection Control Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 30, 2025).

  11. No harm, with potential for more than minimal harm

    Implement a program that monitors antibiotic use.

    Widespread (many residents). CMS level F.

    Health citation F-0881, Infection Control Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 30, 2025).

  12. No harm, with potential for more than minimal harm

    Install emergency lighting that can last at least 1 1/2 hours.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0291, Egress Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 28, 2025).

  13. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 29, 2025).

  14. No harm, with potential for more than minimal harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0521, Services Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 29, 2025).

  15. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 28, 2025).

  16. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (April 29, 2025).

  17. No harm, with potential for more than minimal harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Widespread (many residents). CMS level F.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of March 25, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (April 16, 2024).

  18. No harm, with potential for more than minimal harm

    Establish staff and initial training requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0037, Emergency Preparedness Deficiencies. Inspection of February 2, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 12, 2024).

  19. No harm, with potential for more than minimal harm

    Conduct testing and exercise requirements.

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0039, Emergency Preparedness Deficiencies. Inspection of February 2, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 12, 2024).

  20. No harm, with potential for more than minimal harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0211, Egress Deficiencies. Inspection of February 2, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 12, 2024).

  21. No harm, with potential for more than minimal harm

    Install emergency lighting that can last at least 1 1/2 hours.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0291, Egress Deficiencies. Inspection of February 2, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 22, 2024).

  22. No harm, with potential for more than minimal harm

    Have properly located and lighted "Exit" signs.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0293, Egress Deficiencies. Inspection of February 2, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 22, 2024).

  23. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of February 2, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 23, 2024).

  24. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of February 2, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 12, 2024).

  25. No harm, with potential for more than minimal harm

    Install corridor and hallway doors that block smoke.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of February 2, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 22, 2024).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.