Independent · Federal inspection records, searchable
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Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 145657

The Pearl Of Downers Grove

69 federal citations on record , including 4 at the Immediate Jeopardy level, and 1 federal enforcement actions totaling $30,264.

4 Immediate Jeopardy

Record summary

Federal record · Q1 2026
69
Total citations
45
Last 3 years
9
Actual harm+
1
Federal penalties
$30,264
Total fines
1
Overall ★ rating

Most common violation categories here

Quality of Care33 Resident Rights8 Medication & Pharmacy8 Infection Control5 Abuse & Neglect5

Most common F-tags at this facility

F6867 F6775 F6895 F6845 F6903

Citation history

69 on record
SurveyF-TagViolationSeveritySource
Jan 23, 2026F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DComplaint
Jan 23, 2026F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GComplaint
Apr 14, 2025F881Implement a program that monitors antibiotic use.FStandard
Apr 14, 2025F880Provide and implement an infection prevention and control program.FStandard
Apr 14, 2025F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
Apr 14, 2025F803Ensure 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.FStandard
Apr 14, 2025F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.FStandard
Apr 14, 2025F758Implement 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.DStandard
Apr 14, 2025F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.DStandard
Apr 14, 2025F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.FStandard
Apr 14, 2025F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DStandard
Apr 14, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.GStandard
Apr 14, 2025F688Provide 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.DStandard
Apr 14, 2025F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GStandard
Apr 14, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.DStandard
Apr 14, 2025F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.DStandard
Apr 14, 2025F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.DStandard
Apr 14, 2025F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.EStandard
Apr 14, 2025F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.DStandard
Apr 14, 2025F625Notify 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.FStandard
Apr 14, 2025F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.FStandard
Feb 24, 2025F880Provide and implement an infection prevention and control program.DComplaint
Feb 24, 2025F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DComplaint
Feb 24, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Oct 1, 2024F567Honor the resident's right to manage his or her financial affairs.DComplaint
May 4, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.GComplaint
Apr 30, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.DComplaint
Apr 30, 2024F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.EComplaint
Mar 25, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.DComplaint
Mar 25, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.FComplaint
Mar 25, 2024F585Honor 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.DComplaint
Feb 2, 2024F761Ensure 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.EStandard
Feb 2, 2024F760Ensure that residents are free from significant medication errors.EStandard
Feb 2, 2024F759Ensure medication error rates are not 5 percent or greater.DStandard
Feb 2, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DStandard
Feb 2, 2024F688Provide 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.DStandard
Feb 2, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DStandard
Feb 2, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.EStandard
Feb 2, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.EStandard
Feb 2, 2024F583Keep residents' personal and medical records private and confidential.DStandard
Jan 18, 2024F677Provide care and assistance to perform activities of daily living for any resident who is unable.EComplaint
Aug 23, 2023F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Aug 23, 2023F610Respond appropriately to all alleged violations.DComplaint
Aug 23, 2023F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
May 6, 2023F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Apr 20, 2023F808Ensure 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.DComplaint
Apr 20, 2023F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GComplaint
Apr 20, 2023F685Assist a resident in gaining access to vision and hearing services.EComplaint
Apr 20, 2023F677Provide care and assistance to perform activities of daily living for any resident who is unable.DComplaint
Apr 7, 2023F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.JComplaint
Apr 7, 2023F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Mar 17, 2023F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.FComplaint
Mar 17, 2023F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.FComplaint
Mar 17, 2023F610Respond appropriately to all alleged violations.KComplaint
Mar 17, 2023F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.KComplaint
Mar 17, 2023F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.KComplaint
Mar 1, 2023F883Develop and implement policies and procedures for flu and pneumonia vaccinations.DStandard
Mar 1, 2023F880Provide and implement an infection prevention and control program.EStandard
Mar 1, 2023F760Ensure that residents are free from significant medication errors.DStandard
Mar 1, 2023F759Ensure medication error rates are not 5 percent or greater.DStandard
Mar 1, 2023F758Implement 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.DStandard
Mar 1, 2023F695Provide safe and appropriate respiratory care for a resident when needed.DStandard
Mar 1, 2023F692Provide enough food/fluids to maintain a resident's health.EStandard
Mar 1, 2023F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DStandard
Mar 1, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DStandard
Mar 1, 2023F688Provide 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.DStandard
Mar 1, 2023F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DStandard
Mar 1, 2023F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DStandard
Mar 1, 2023F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DStandard

Federal enforcement history

Federal regulators have imposed 1 enforcement actions against this facility, including 1 civil money penalties totaling $30,264 .

DateTypeFinePayment denial
Apr 14, 2025Fine$30,264—
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

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