Deficiency timeline
THE PEARL OF DOWNERS GROVE
Dated inspection findings, penalties, and correction notes for this nursing home in Downers Grove, IL. Newest events first.
- Class IIIPotential for more than minimal harm (E)Complaint-relatedcms
F0690: Quality of Life and Care
Quality of life & care
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 May 19, 2026
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0686: Quality of Life and Care
Quality of life & care
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Feb 5, 2026
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0690: Quality of Life and Care
Quality of life & care
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 Feb 5, 2026
- Class IIIPotential for more than minimal harm (F)cms
F0623: Resident Rights
Resident rights
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected Apr 30, 2025
- Class IIIPotential for more than minimal harm (F)cms
F0625: Resident Rights
Resident rights
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.
Corrected Apr 30, 2025
- Class IIIPotential for more than minimal harm (F)cms
F0725: Nursing and Physician Services
Nursing & physician services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected Apr 30, 2025
- Class IIIPotential for more than minimal harm (F)cms
F0801: Nutrition and Dietary
Nutrition & dietary
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.
Corrected Apr 30, 2025
- Class IIIPotential for more than minimal harm (F)cms
F0803: Nutrition and Dietary
Nutrition & dietary
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 Apr 30, 2025
- Class IIIPotential for more than minimal harm (F)cms
F0812: Nutrition and Dietary
Nutrition & dietary
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected Apr 30, 2025
- Class IIIPotential for more than minimal harm (F)cms
F0880: Infection Control
Infection control
Provide and implement an infection prevention and control program.
Corrected Apr 30, 2025
- Class IIIPotential for more than minimal harm (F)cms
F0881: Infection Control
Infection control
Implement a program that monitors antibiotic use.
Corrected Apr 30, 2025
- Class IIIPotential for more than minimal harm (E)cms
F0656: Resident Assessment and Care Planning
Assessment & care planning
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected May 1, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0657: Resident Assessment and Care Planning
Assessment & care planning
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected Apr 30, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0676: Quality of Life and Care
Quality of life & care
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected Apr 30, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0677: Quality of Life and Care
Quality of life & care
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Apr 30, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0688: Quality of Life and Care
Quality of life & care
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 Apr 30, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0690: Quality of Life and Care
Quality of life & care
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 Apr 30, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0744: Quality of Life and Care
Quality of life & care
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected Apr 30, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0758: Pharmacy Service
Pharmacy services
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.
Corrected Apr 30, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0644: Resident Assessment and Care Planning
Assessment & care planning
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected Apr 30, 2025
- Class IIActual harm (G)cms
F0686: Quality of Life and Care
Quality of life & care
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Apr 30, 2025
- Class IIActual harm (G)cms
F0689: Quality of Life and Care
Quality of life & care
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Apr 30, 2025
- Fine $30,794cms
CMS fine
Civil money penalty recorded in CMS Nursing Home Compare.
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0686: Quality of Life and Care
Quality of life & care
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Mar 26, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0880: Infection Control
Infection control
Provide and implement an infection prevention and control program.
Corrected Mar 24, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0684: Quality of Life and Care
Quality of life & care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Mar 24, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0567: Resident Rights
Resident rights
Honor the resident's right to manage his or her financial affairs.
Corrected Nov 15, 2024
- Class IIActual harm (G)Complaint-relatedcms
F0689: Quality of Life and Care
Quality of life & care
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 8, 2024
- Class IIIPotential for more than minimal harm (E)Complaint-relatedcms
F0584: Resident Rights
Resident rights
Honor 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.
Corrected May 9, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0677: Quality of Life and Care
Quality of life & care
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected May 9, 2024
- Class IIIPotential for more than minimal harm (F)Complaint-relatedcms
F0689: Quality of Life and Care
Quality of life & care
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Apr 16, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0585: Resident Rights
Resident rights
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 Apr 16, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0755: Pharmacy Service
Pharmacy services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected Apr 16, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0689: Quality of Life and Care
Quality of life & care
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Feb 27, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0759: Pharmacy Service
Pharmacy services
Ensure medication error rates are not 5 percent or greater.
Corrected Feb 27, 2024
- Class IIIPotential for more than minimal harm (E)cms
F0760: Pharmacy Service
Pharmacy services
Ensure that residents are free from significant medication errors.
Corrected Feb 27, 2024
- Class IIIPotential for more than minimal harm (E)cms
F0684: Quality of Life and Care
Quality of life & care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Feb 27, 2024
- Class IIIPotential for more than minimal harm (E)cms
F0677: Quality of Life and Care
Quality of life & care
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Feb 27, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0583: Resident Rights
Resident rights
Keep residents' personal and medical records private and confidential.
Corrected Feb 27, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0686: Quality of Life and Care
Quality of life & care
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Feb 27, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0688: Quality of Life and Care
Quality of life & care
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 Feb 27, 2024
- Class IIIPotential for more than minimal harm (E)cms
F0761: Pharmacy Service
Pharmacy services
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 Feb 27, 2024
- Class IIIPotential for more than minimal harm (E)Complaint-relatedcms
F0677: Quality of Life and Care
Quality of life & care
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Feb 14, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0610: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Respond appropriately to all alleged violations.
Corrected Sep 13, 2023
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0684: Quality of Life and Care
Quality of life & care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Sep 13, 2023
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0609: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected Sep 13, 2023
- Class IIIPotential for more than minimal harm (E)cms
F0880: Infection Control
Infection control
Provide and implement an infection prevention and control program.
Corrected Mar 24, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0550: Resident Rights
Resident rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected Mar 24, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0684: Quality of Life and Care
Quality of life & care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Mar 24, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0686: Quality of Life and Care
Quality of life & care
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Mar 24, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0688: Quality of Life and Care
Quality of life & care
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 Mar 24, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0689: Quality of Life and Care
Quality of life & care
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Mar 24, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0690: Quality of Life and Care
Quality of life & care
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 Mar 24, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0695: Quality of Life and Care
Quality of life & care
Provide safe and appropriate respiratory care for a resident when needed.
Corrected Mar 24, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0758: Pharmacy Service
Pharmacy services
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.
Corrected Mar 24, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0759: Pharmacy Service
Pharmacy services
Ensure medication error rates are not 5 percent or greater.
Corrected Mar 24, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0760: Pharmacy Service
Pharmacy services
Ensure that residents are free from significant medication errors.
Corrected Mar 24, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0883: Infection Control
Infection control
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected Mar 24, 2023
- Class IIIPotential for more than minimal harm (E)cms
F0692: Quality of Life and Care
Quality of life & care
Provide enough food/fluids to maintain a resident's health.
Corrected Mar 24, 2023
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AHCA class rollups without individual citation dates appear as a single summary row. CMS nursing home deficiencies include survey date, tag, category, scope/severity, and fine amounts when published. Back to community profile