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 23 of 23 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. 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).

  4. 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).

  5. 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).

  6. 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).

  7. 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).

  8. 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).

  9. 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).

  10. 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).

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

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0690, Quality of Life and Care Deficiencies. Inspection of May 17, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (May 19, 2026).

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

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (May 1, 2025).

  13. 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.

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

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of July 9, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (July 14, 2026).

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

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

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

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of January 23, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (February 5, 2026).

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

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

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

    Health citation F-0690, Quality of Life and Care Deficiencies. Inspection of January 23, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (February 5, 2026).

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

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

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

    Health citation F-0644, Resident Assessment and Care Planning Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

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

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

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

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

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

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

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

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

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

    Health citation F-0676, 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).

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

    Provide care and assistance to perform activities of daily living for any resident who is unable.

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

    Health citation F-0677, 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).

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

    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.

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

    Health citation F-0688, 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).

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

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

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

    Health citation F-0690, 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).

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

    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

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

    Health citation F-0744, 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).

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

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

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

    Health citation F-0758, Pharmacy Service Deficiencies. Inspection of April 14, 2025. Found during a standard inspection.

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

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of October 1, 2026. Inspection results describe the home at the time of each inspection.