Compiled from official CMS federal data
THE PEARL OF DOWNERS GROVE, DOWNERS GROVE, IL — Violations & Inspection Reports
Does THE PEARL OF DOWNERS GROVE have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), THE PEARL OF DOWNERS GROVE (CCN 145657), in DOWNERS GROVE, IL, has federal inspection findings.
In its current inspection cycle, CMS cited the facility for 21 deficiencies; the most severe is rated G, a level CMS classifies as actual harm. The latest standard health inspection on file is dated 2025-04-14. Earlier-cycle citations appear in the dated timeline below as historical, not current. CMS has $30,794 in civil money penalties on file against the facility. The record also includes 2 abuse- or neglect-related citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series; most recent Aug 2023). This page restates the federal record and draws no conclusion of its own.
Abuse-, fall-, and care-related findings on the federal record
- 2 citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series) — most recent Aug 2023.
- 5 citations for accident hazards or inadequate supervision (F689) — the deficiency family behind fall-related findings; most recent Apr 2025.
- 5 pressure-ulcer care citations (F686) — the consumer term is "bedsores"; most recent Jan 2026.
- 1 nutrition and hydration citation (F692) — the consumer terms are "malnutrition" and "dehydration"; most recent Mar 2023.
- 16 findings on file from complaint-triggered inspections.
Every figure above restates CMS’s own dated record; this page draws no conclusion of its own. Strict state filing deadlines can apply to nursing-home injury claims — a licensed attorney in your state can review this record.
FOR FAMILIES
What brings you to this record?
The Federal Record
At its most recent federal inspection, CMS cited this facility for 2 deficiencies that CMS classified as "actual harm" — its category for harm that reached a resident, above the level of risk alone.
Below is this facility's federal inspection record as on file with CMS.
Scope & Severity — current cycle
CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations.
Civil money penalties on file
$30,794
Have a lawyer review this record →
About this record: Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
Deficiency timeline
Citations are listed by scope/severity (most severe first), not chronologically; each entry is labeled current-cycle or historical.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
54 more citations on file — Abuse & neglect 2 · Accidents & supervision 3 · Pressure ulcers 4 · Nutrition & hydration 1 · Medication & pharmacy 8 · Resident rights 5 · Other citations 26 (expand)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Implement a program that monitors antibiotic use.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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.
Provide and implement an infection prevention and control program.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Provide care and assistance to perform activities of daily living for any resident who is unable.
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.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide and implement an infection prevention and control program.
Honor the resident's right to manage his or her financial affairs.
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.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide care and assistance to perform activities of daily living for any resident who is unable.
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.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that residents are free from significant medication errors.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure medication error rates are not 5 percent or greater.
Keep residents' personal and medical records private and confidential.
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.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Respond appropriately to all alleged violations.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide enough food/fluids to maintain a resident's health.
Provide and implement an infection prevention and control program.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide safe and appropriate respiratory care for a resident when needed.
Develop and implement policies and procedures for flu and pneumonia vaccinations.
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.
Ensure medication error rates are not 5 percent or greater.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Ensure that residents are free from significant medication errors.
Overall CMS star rating
This facility: 1 · CMS state average: 2.6
Both figures as published by CMS.
You may be reading this record for the first time.
If something happened to someone you love at this facility, this federal record may be new to you today. The company that operates a nursing home, by contrast, is rarely seeing records like this for the first time — operators like these typically retain standing legal, risk, and insurance teams whose routine work includes records exactly like the one on this page. That is not a judgment of this facility; it is how the business is structured. Because strict time limits can apply, families often find it helps to have a qualified person review the record with them sooner rather than later.
Your federal record — tap to preview
Federal record
THE PEARL OF DOWNERS GROVE — Federal Record
Your answers below fill this section.
- —
- —
- —
- —
- —
- —
SECTION 7 — CASE CONTEXT
Add what you saw at THE PEARL OF DOWNERS GROVE to this record
No call centers, no auctions. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. The federal record is a point-in-time inspection record and may understate what actually occurred. CareSentinel is operated by Nodal Logics LLC.
Strict time limits can apply to taking legal action — consider consulting a qualified attorney promptly.
If you believe a resident is in immediate danger, call 911. Care concerns can also be reported at no cost to your state survey agency or the Long-Term Care Ombudsman program (ltcombudsman.org) — independent of any legal inquiry.
How to read this record
Making sense of a CMS inspection record
CMS scores every citation on a grid from A to L, combining how widespread a finding was with how serious it was. A–C is a deficiency CMS classifies as no harm; D–F as the potential for harm; G–I as actual harm that reached a resident; and J–L as immediate jeopardy, CMS’s most serious level. Later letters mark more serious findings.
Three questions to ask on a tour
- How is the home staffed on nights, weekends, and holidays?
- What happens when a resident’s condition changes suddenly?
- How, and how quickly, are families told about an incident?