Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Pearl Of Downers Grove during CMS and state inspections, most recent first.
A facility failed to provide appropriate catheter care and perineal hygiene for four residents with urinary catheters and bowel incontinence. Staff were observed cleaning catheter tubing and surrounding areas with the same wipe using repeated up-and-down strokes, leaving adherent residue present on the tubing and insertion areas for multiple residents. One resident was also found with dried feces on the brief, scrotal area, inner thigh, catheter anchoring device, and tubing, while another was receiving ABX for a UTI and all were documented as needing staff-assisted toileting hygiene and catheter care to prevent UTIs.
A resident who was quadriplegic, non-verbal, on hospice, and at high risk for pressure injuries developed a large left ischial pressure injury after staff failed to promptly assess, document, and treat a newly reported wound. A CNA reported a red, bleeding area on the buttocks to an RN, but the RN did not assess or document the wound and no dressing was applied. The wound nurse learned of the issue from an aide the next day and found a large deep tissue injury without a dressing, which later progressed to an unstageable pressure injury. The resident had a prior healed ischial ulcer, used a wedge and low air loss mattress, depended entirely on staff for repositioning, and staff acknowledged that new wounds should be immediately reported, assessed, documented, and managed according to facility policy.
A resident with multiple urologic and medical conditions was found with an indwelling urinary catheter drainage bag hanging from a bedside table drawer handle, with tubing not maintained below bladder level and the securement device not attached to the leg. The resident reported prior penile tearing related to lack of anchoring and infrequent emptying of the drainage bag and stated a request for a new anchoring device the previous day was not addressed. An LPN acknowledged the presence of a penile tear, had not assessed the area that morning, and reported the bag had contained 1600 cc of urine earlier, despite expectations that bags be emptied at least each shift. The ADON described required catheter care practices, including use of a stat lock and keeping the bag below bladder level, and the resident’s care plan included securing tubing and maintaining bag position but did not address the existing meatal tear, contrary to the facility’s catheter policy requiring securement and support of tubing.
A resident at moderate risk for pressure injuries developed a deep tissue injury (DTI) due to the facility's failure to implement and document appropriate preventive and treatment interventions. Despite being assessed as high risk, the care plan lacked specific measures to prevent pressure injuries while the resident was seated. Observations revealed that pressure-relieving boots were not used as ordered, and the resident's feet were not properly offloaded, contributing to the injury's development and persistence.
A resident with severe cognitive impairment sustained significant bruising and pain due to a fall while being transported in a wheelchair without leg rests by a CNA. The resident's foot got caught underneath the wheelchair, causing her to slide out and hit her head. Staff interviews confirmed that the use of leg rests could have prevented the fall.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses and insufficient ADL care for residents. Several residents reported extended wait times for assistance, particularly during evening and overnight shifts. Staffing records showed a discrepancy between required and actual CNA numbers, with units often understaffed, affecting care quality.
The facility failed to employ a qualified food service manager for its 83 residents. The Food Service Manager had not enrolled in or completed a dietary manager course, although she held a Serve Safe Sanitation certification. The facility did not provide documentation verifying her qualifications.
The facility failed to serve meals according to the dietitian-approved menu, affecting 82 residents on oral diets. Mechanical soft diets were served without bread, and hamburger patties were underweight, providing insufficient protein. The dietitian confirmed the menu did not meet the expected protein requirements. Additionally, weekly menus consistently lacked required servings of grains, breads, vegetables, and fruits, indicating systemic issues in menu planning and execution.
The facility failed to maintain proper hand hygiene and sanitizing procedures in the dietary department. A dietary aide handled both soiled and clean dishes without washing hands or changing gloves, contrary to facility policy. Additionally, the sanitizing solution used for food contact surfaces was below the required concentration, failing to meet the manufacturer's instructions.
The facility failed to conduct comprehensive infection surveillance, maintain a complete water management program for Legionella, and adhere to Enhanced Barrier Precautions (EBP) and hand hygiene policies. The Director of Nursing did not complete McGeer's Criteria assessments for infections, and the Maintenance Director did not document water temperatures or perform chlorine testing. An LPN failed to wear PPE and perform hand hygiene during resident care, and a wound nurse was unaware of a resident's EBP order, failing to use PPE while examining a wound.
The facility failed to follow its antibiotic stewardship policy, affecting all residents. The DON did not use McGeer's Criteria to assess infections, leading to inappropriate antibiotic prescriptions. Monitoring of antibiotic use was incomplete, and staff were not instructed on using McGeer's Criteria, indicating systemic issues in training and communication.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in addressing specific care needs. A resident with an indwelling urinary catheter lacked a care plan for its use and infection prevention. Another resident with a pressure injury had inadequate care plan interventions for pressure relief. Additionally, residents with psychiatric and cognitive impairments had care plans that did not address their diagnoses or medication use.
A facility failed to refer a resident with a new diagnosis of unspecified psychosis for a Level II PASRR, as required for significant changes in mental health conditions. The resident was initially admitted with major depressive disorder, anxiety disorder, and seizures. Staff interviews revealed confusion and lack of responsibility regarding the PASRR process, with the Admissions Coordinator unaware of the need for re-screening and the Social Services Director not involved in the process. The facility's policy mandates rescreening for new mental health diagnoses, but no documentation was found for this resident.
A facility failed to accurately complete a PASRR for a resident with mental health conditions, as the Admissions Coordinator, who was not a qualified healthcare professional, omitted the resident's mental health diagnoses and medications from the submission. This led to an incorrect Level I outcome, despite the resident's documented conditions and prescribed medications.
A facility failed to update a care plan with specific fall-prevention interventions for a cognitively impaired resident with a history of falls. The resident fell while being transported in a wheelchair without leg rests, resulting in a bruise and hospital evaluation. Despite prior falls, the care plan lacked updated interventions, and no root cause analysis was conducted. The Acting DON confirmed no care plan revision or targeted prevention measures were implemented.
A resident did not receive restorative therapy as per facility policy. The resident expressed a desire for therapy, and a referral was made to the DON, who was unaware of it. The facility's policy requires screening for restorative care, but understaffing led to CNAs not providing therapy.
The facility failed to provide adequate nail care to three residents who were dependent on staff for ADLs. Observations revealed long, untrimmed fingernails with debris, and some embedded into palms due to contracted hands. Despite care plans indicating a need for total assistance, these residents did not receive necessary nail care, compromising their comfort and hygiene.
The facility failed to provide necessary interventions and positioning devices for two residents with limited range of motion, leading to further contractures. One resident was found without a splint for her contracted hand, and her care plan lacked specific interventions. Another resident had a flexion contracture and was supposed to have a splint, but it was not provided. The facility's policy on mobility and range of motion was not followed.
A facility failed to document the justification for the continued use of an indwelling urinary catheter for a resident who developed a urinary tract infection. The resident, with multiple health issues and cognitive impairment, had an indwelling catheter without documented reasons or care instructions. The care plan lacked interventions for infection prevention, and the Acting DON admitted there was no documentation or policy for evaluating catheter use.
A facility failed to create a person-centered care plan for a resident with Alzheimer's disease, despite the resident's moderate cognitive impairment and multiple diagnoses. The care plan, completed in March, lacked specific interventions for dementia care, which was acknowledged by the Social Services Director.
A resident with multiple non-pressure wounds did not receive the prescribed wound care treatments as ordered by the wound physician. The Treatment Administration Record did not reflect the physician's orders for xeroform gauze and gauze roll, leading to inappropriate wound care. Observations and interviews confirmed the facility's failure to adhere to the prescribed treatment plans.
The facility failed to implement ordered pressure ulcer treatments for three residents. A resident with a Stage 4 pressure ulcer did not receive the prescribed xeroform gauze or silver sulfadiazine, and another resident's deep tissue injuries were not treated according to the physician's plan. Additionally, a third resident's treatment plan was not updated in the TAR, leading to improper care. The facility did not adhere to its policy on pressure injury prevention and management.
A facility failed to follow infection control protocols during wound care for a resident in isolation for MRSA and C. Striatum. An LPN brought a treatment cart into the isolation room and did not change gloves or perform hand hygiene during the dressing change, risking cross-contamination. The Infection Preventionist confirmed that such actions violate facility policies.
A facility failed to honor a resident's right to manage their financial affairs by applying to become the representative payee for the resident's Social Security income without the spouse's consent. Despite the spouse being the designated Power of Attorney, the facility's Business Office Manager proceeded with the application due to unpaid room and board fees, inaccurately stating that the resident owed no money. The facility's administrator acknowledged that family permission should have been obtained.
A resident with a history of knee fractures and dementia sustained left and right femoral fractures due to improper transfer assistance. The CNA performed a pivot transfer without a gait belt, leading to the injuries. The care plan was incomplete and not updated, contributing to the incident.
The facility failed to maintain clean and sanitary resident rooms for four residents. Observations showed full garbage containers, food debris, and soiled items in bathrooms and rooms. Staff interviews revealed insufficient housekeeping coverage, leading to some rooms not being cleaned daily as required. The administrator acknowledged recent complaints and confirmed the daily cleaning policy.
The facility failed to provide adequate incontinence care for two residents who required staff assistance. One resident was left in a saturated brief for over an hour despite complaints of pain, while another was found with a saturated brief that had leaked urine onto the bed sheet. The Director of Nursing stated that incontinence care should be provided every two hours, but this standard was not met.
Inadequate catheter and perineal care for residents with urinary catheters
Penalty
Summary
The facility failed to provide appropriate catheter care and perineal hygiene for four residents with urinary catheters who were also incontinent of bowel. The report states that each resident had a care plan identifying the need for catheter care and perineal hygiene to prevent urinary tract infections, and each was dependent on staff assistance for toileting hygiene. The residents involved were receiving care for conditions including urinary obstructive uropathy, neurogenic bladder, and recurrent UTIs, and one resident was receiving Bactrim DS for treatment of a UTI at the time of observation. During observations, staff were seen cleaning catheter tubing and surrounding areas with the same wipe using repeated upward and downward strokes, rather than cleaning in a downward direction with a clean cloth. One resident’s catheter tubing had thick-brown adherent residue up to the insertion site, another had thick red-brown adherent residue throughout the scrotal and penile area and at the insertion site, and a third had brown adherent residue near the suprapubic catheter insertion site. In these instances, the residue remained present after the cleaning attempts, and the catheter care was observed by the IP Nurse in two cases, who educated staff on proper catheter cleaning. For another resident, the brief was soiled with dried feces and the scrotal area, inner thigh, catheter anchoring device, and tubing were also soiled. Staff rendered perineal care, but the soiled catheter anchoring device remained in place and the catheter connection-port site was being held by that soiled device. The facility policy titled Perineal Care/Indwelling Catheter required daily and as-needed perineal care for residents with Foley catheters and directed staff to clean catheter tubing using a downward stroke with a clean cloth.
Failure to Timely Identify, Assess, and Treat a High-Risk Resident’s New Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to timely identify, assess, document, and initiate treatment orders for a newly developed pressure injury in a resident who was quadriplegic, non-verbal, totally dependent on staff for all care, and at high risk for pressure injuries. The resident had a history of a facility-acquired Stage 2 ischial pressure ulcer that had healed and was on hospice care, with existing orders for a wedge cushion and low air loss mattress. Braden Scale assessments showed the resident progressed from moderate to high risk for pressure injury development, and the resident preferred lying on the left side, had a prior healed wound in the same area, and was dependent on staff for repositioning. On one night, a CNA reported to the night RN that the resident had a wound on the buttocks, described as red and bleeding on the ischium. The RN acknowledged being notified but did not assess the wound, did not apply or ensure a dressing was in place, did not document the wound in the medical record, and only verbally notified the wound nurse the following morning. The wound nurse later stated that any new wounds should be reported to her so she can assess, photograph, notify the physician and family, and obtain treatment orders, but confirmed she was not notified by nursing staff and instead learned of the wound from an aide. The EHR contained no documentation of the left ischial pressure area on the date the night RN was notified. When the wound nurse assessed the resident the next day, she found a large deep tissue injury on the left ischium measuring 12 cm by 9 cm, with maroon discoloration, blood-filled blister, moderate serosanguineous drainage, and peri-wound erythema, maceration, and bogginess, and noted there was no dressing on the area. Subsequent wound progress notes documented the injury as a deep tissue injury and later as an unstageable pressure injury with full-thickness skin and tissue loss. Staff interviews reflected confusion about how the wound became so large in a short time, acknowledgment that the resident was at great risk due to immobility and prior skin breakdown, and recognition that the resident should have had a protective dressing to the ischial area and that new wounds were to be immediately reported, assessed, documented, and communicated per facility policy on treatment and services to prevent and heal pressure injuries.
Improper Management of Indwelling Urinary Catheter and Lack of Securement
Penalty
Summary
Failure to provide appropriate catheter care occurred when a resident with an indwelling urinary catheter was observed with the drainage bag hanging from the top drawer handle of the bedside table, with the drainage tubing pulled back to the right side and not maintained below the level of the bladder. The resident’s anchoring device was folded around the tubing and not secured to his leg. The resident, who had multiple diagnoses including obstructive and reflux uropathy, benign prostatic hyperplasia, and other comorbidities, reported having tearing to his penis from a previous facility because staff were not using the anchoring device and were not emptying the drainage bag, allowing the weight of the bag to pull on his penis. He stated he had requested a new anchoring device the previous day, but staff did not act on his request. During interview, an LPN acknowledged the resident had a catheter, was followed by a urologist, and had a penile tear, which she attributed to poor hygiene, and stated she did not think the wound nurse was doing anything for it. She reported she had not assessed the area that morning and stated that 1600 cc of urine had been emptied from the drainage bag that morning, and that staff should empty the bag every shift and as needed. When the LPN entered the room, she questioned why the drainage bag was hooked on the top drawer handle, lifted the bag above the level of the bladder, and then handed it to an aide to reposition. The resident’s meatal tear was present at the catheter insertion site without a securement device in place, which the LPN confirmed should have been used to prevent pulling. The ADON stated catheter care should be done every shift and as needed, including emptying the bag at least every shift, using a privacy bag, and ensuring the stat lock is in working condition, and explained that a full bag can put pressure on the urethra and cause urine backflow and potential bacterial infections, and that stat locks are used to prevent trauma or tearing. The resident’s care plan included interventions to secure tubing to prevent pulling and to keep the drainage bag below bladder level, but did not address the existing meatal tear. The facility’s indwelling catheter policy required consideration of a securement device and support of catheter tubing to prevent tugging or inadvertent removal.
Failure to Prevent and Manage Pressure Injury
Penalty
Summary
The facility failed to implement appropriate interventions to prevent and treat a pressure injury for a resident identified as R59, who was at moderate risk for pressure injuries. R59 was admitted with multiple diagnoses, including pulmonary embolism, diabetes, and vascular dementia, and required substantial assistance for mobility. Despite being assessed as high risk for pressure injuries in October 2024, the care plan did not include specific interventions to prevent pressure injuries on her lower extremities while sitting in a chair. This oversight led to the development of a deep tissue injury (DTI) on her right plantar foot, which was unstageable due to necrotic tissue. Observations and interviews revealed that the facility's staff, including the wound nurse, were not consistently implementing the prescribed interventions. The resident's pressure-relieving boots were not being used as ordered, and her feet were not properly offloaded, contributing to the development and persistence of the DTI. The wound nurse acknowledged that the injury had been present for months and was caused by the resident's sitting position. The care plan lacked documentation of interventions for the diagnosed pressure injury and did not include enhanced barrier precautions related to the wound. The facility's policy on pressure injury prevention and management was not followed, as evidenced by the lack of proper assessment and documentation of interventions. The physician confirmed that the facility should have had preventive measures in place, such as repositioning and the use of pressure-relieving devices, which were not documented or consistently implemented. The failure to adhere to the facility's policy and the absence of a comprehensive care plan for pressure injury prevention and management resulted in the development of the DTI for R59.
Failure to Ensure Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure safe wheelchair transport for a cognitively impaired resident, resulting in the resident sustaining significant bruising and pain. The resident, who has severe cognitive impairment and requires substantial assistance during wheelchair transport, was being transported by a CNA without the use of wheelchair leg rests. This oversight led to the resident's foot getting caught underneath the wheelchair, causing the resident to slide out and fall, hitting her head and sustaining a bruise on the right side of her face, forehead, and orbital area. Interviews with staff, including LPNs and CNAs, confirmed that the fall could have been prevented if leg rests were used during transport. The facility's incident report and nurse's progress notes corroborate the details of the fall incident. Despite the absence of a formal policy for safe wheelchair transport, the skilled therapy department's practice of using leg rests was not followed, contributing to the accident.
Inadequate Staffing Leads to Delayed Care and Resident Concerns
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely response to call lights and adequate assistance with activities of daily living (ADL) care, affecting all 83 residents. During a resident meeting, several residents reported experiencing extended wait times for call light responses, particularly during the evening and overnight shifts. One resident expressed anxiety due to waiting 2 to 3 hours for call light responses, which delayed incontinence care and access to PRN medication. Another resident was unable to attend a meeting because a CNA did not assist him in getting up, despite his request to participate in activities. The Resident Council Meeting minutes from December 2024 to March 2025 consistently documented concerns about delayed call light responses, insufficient care on weekends, and delayed medication administration. The facility's staffing records revealed a significant discrepancy between the required and actual number of CNAs on duty. The facility assessment indicated a need for 30 CNAs in a 24-hour period, but daily assignment sheets showed only 20 CNAs were working. Units with residents requiring two staff assists were often staffed with only one CNA, leading to inadequate care. The staffing coordinator acknowledged that CNAs from other units or nurses could assist, but this could leave units understaffed. The administrator admitted that an evaluation of resident care needs in relation to CNA staffing was not conducted in response to the concerns raised in Resident Council Meetings.
Facility Lacks Qualified Food Service Manager
Penalty
Summary
The facility failed to employ a qualified food service manager, affecting all 83 residents. The Long Term Care Facility Application for Medicare and Medicaid indicated a census of 83 residents. On April 9, 2025, the Food Service Manager (V5) admitted during an interview that she had not enrolled in or completed a dietary manager course. Although she had recently received a link to register for the course, she had not yet enrolled. V5 possessed a Serve Safe Sanitation certification, valid from November 22, 2024, to November 22, 2029, but lacked any other certifications required for her role. As of April 10, 2025, the facility had not provided documentation to verify V5's qualifications as the Food Service Manager.
Deficiency in Menu Compliance and Nutritional Provision
Penalty
Summary
The facility failed to prepare and serve food to residents according to the planned and dietitian-approved menu, affecting all 82 residents receiving oral diets. During a lunch service, a dietary aide served ground meals without bread to residents on mechanical soft diets, contrary to the menu which specified a ground hamburger on a bun. Additionally, the hamburger patties served were underweight, providing less than the expected 3 ounces of protein. The food service manager confirmed the discrepancy in protein content and stated that the dietitian had instructed not to serve bread to residents on mechanical soft diets. The dietitian confirmed that mechanical soft diets should include a soft piece of bread equivalent to the regular menu's bread servings. The dietitian also noted that the menu did not provide the expected 6 ounces of high-quality protein per day, as the hamburger patty, omelet, and ravioli servings were insufficient. The facility's menu policy requires that menus are followed as written to meet residents' nutritional needs, but the served menu did not meet these requirements. Further review of the facility's weekly menus revealed consistent shortages in servings of grains, breads, vegetables, and fruits across multiple days. The facility's meal pattern document specifies daily servings for these food groups, but the approved menus fell short of these requirements. This indicates a systemic issue in menu planning and execution, leading to inadequate nutrition for the residents.
Deficiencies in Hand Hygiene and Sanitizing Procedures in Dietary Department
Penalty
Summary
The facility failed to adhere to proper hand hygiene and sanitizing procedures in the dietary department, affecting all 83 residents. During an observation in the dish machine room, a dietary aide, identified as V15, was seen handling both soiled and clean dishes without washing hands or changing gloves as required by the facility's policy. V15 removed gloves after handling dirty dishes but did not wash hands before touching clean, sanitized bowls and other dishware, which were then placed into storage. This practice was contrary to the facility's policy, which mandates handwashing between glove use to prevent cross-contamination. Additionally, the facility did not maintain the correct concentration of sanitizing solution for food contact surfaces. During a lunch meal preparation, a dietary aide, V6, used a sanitizing solution with a concentration of 100 ppm, which was below the required 150-400 ppm as per the facility's chemical manufacturing product information. The Food Service Director, V5, confirmed that the sanitizing solution should be within the specified range, indicating a failure to comply with the manufacturer's instructions for maintaining proper sanitizing standards.
Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to conduct comprehensive infection surveillance for resident infections, as evidenced by the Director of Nursing (V2) not completing McGeer's Criteria assessments for residents with infections. Instead, V2 relied on a monthly list of residents who received antibiotics to track infection trends, which did not provide accurate surveillance. The Order Listing Reports for January, February, and March 2025 showed that anti-infectives were prescribed, but no surveillance was completed. This lack of comprehensive infection surveillance was acknowledged by the facility's Administrator (V1), who stated that V2 should have been conducting surveillance for all infections identified in the facility. The facility also failed to maintain a complete water management program for Legionella. The Maintenance Director (V23) admitted to not documenting water temperatures of hot water heaters or tanks, not performing chlorine testing, and not maintaining documentation of running water in vacant resident rooms. V23 was unaware of the control measures for the facility's water management plan for Legionella and did not know how to respond if control measures were not met. The facility lacked documentation to show a water management plan containing areas at risk for Legionella growth, control measures, or routine safety logs for control measures. Additionally, the facility failed to adhere to Enhanced Barrier Precautions (EBP) and hand hygiene policies. An LPN (V28) did not wear the required PPE gown while administering medications and flushing a gastric tube for a resident on EBP status. V28 also failed to perform hand hygiene before and after glove use during medication administration and insulin injection procedures. Another resident (R29) with multiple infections did not have appropriate contact precautions signage outside their room, and a wound nurse (V12) was unaware of a resident's order for EBP, failing to use PPE while examining the resident's wound. These actions were not in compliance with the facility's policies on EBP, hand hygiene, and infection precautions.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship policy, affecting all 83 residents. The Director of Nursing (DON), who also served as the Infection Preventionist, admitted to not using McGeer's Criteria to assess infections since starting in November 2024. This oversight led to the inappropriate prescription of antibiotics, as evidenced by a resident who was prescribed antibiotics based on laboratory results without exhibiting any symptoms. The DON acknowledged that the resident's laboratory results did not meet McGeer's Criteria, indicating a failure to ensure antibiotics were necessary. Further investigation revealed that the facility's antibiotic use monitoring was incomplete. The DON only reviewed antibiotic use for residents currently residing in the facility at the time of report generation, rather than for all residents who received antibiotics each month. This resulted in inaccurate monitoring of antibiotic use, as shown by the Order Listing Reports for January, February, and March 2025, which indicated that no surveillance was completed for the prescribed anti-infectives during these months. Interviews with nursing staff, including agency RNs, revealed a lack of instruction and awareness regarding the use of McGeer's Criteria for assessing suspected infections. Several nurses were unaware of what McGeer's Criteria was or how to apply it, indicating a systemic issue in the facility's training and communication regarding infection assessment protocols. The facility's policy emphasized the importance of using McGeer's Criteria to classify infections, but this standard was not communicated effectively to the staff, leading to the deficiency.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for several residents, leading to deficiencies in addressing their specific care needs. One resident, admitted with multiple diagnoses including chronic atrial fibrillation and morbid obesity, was observed with an indwelling urinary catheter but lacked a care plan addressing its use, care, or infection prevention. Additionally, the resident's care plan inaccurately described their continence status and did not address their dependence on staff for activities of daily living (ADL) such as bathing and dressing. Another resident, diagnosed with conditions including pulmonary embolism and vascular dementia, had a facility-acquired pressure injury that was not adequately addressed in their care plan. Despite having physician orders for wound care and offloading interventions, the care plan did not include pressure-relieving interventions for the resident's sitting position, which contributed to the development of the pressure injury. Furthermore, the care plan failed to incorporate enhanced barrier precautions related to the resident's wound. Additional deficiencies were noted for residents with psychiatric and cognitive impairments. One resident with bipolar disorder and major depressive disorder was receiving multiple psychotropic medications, yet their care plan did not address these diagnoses or the use of such medications. Another resident with Alzheimer's disease had a care plan that lacked individualized interventions for dementia care, despite the diagnosis being known and discussed during care plan meetings. These omissions highlight the facility's failure to develop person-centered care plans that meet the residents' comprehensive medical, nursing, and psychosocial needs.
Failure to Conduct Level II PASRR for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident with a new mental health diagnosis for a Level II PASRR, which is required when there is a significant change in a resident's mental health condition. The resident, identified as R19, was admitted with diagnoses including major depressive disorder, anxiety disorder, and seizures. On October 5, 2024, R19 was diagnosed with unspecified psychosis, a condition that necessitates a Level II PASRR referral. However, the facility did not complete a rescreening for R19 following this new diagnosis. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASRR process. The Admissions Coordinator, V26, stated she had never submitted a re-screening for a resident's Level I PASRR following a new mental health diagnosis. The Social Services Director, V24, indicated he was not involved in the PASRR process and could not access the necessary system. The Director of Nursing, V2, acknowledged the new diagnosis but stated she was not involved in PASRRs. The facility's policy requires a new screen to be submitted if changes occur or new information refutes previous findings, but there was no documentation of a rescreening for R19 after the diagnosis of psychosis.
Inaccurate PASRR Completion for Resident with Mental Health Conditions
Penalty
Summary
The facility failed to adhere to its policy for completing an accurate PASRR (Preadmission Screening and Resident Review) for a newly admitted resident, identified as R19. The deficiency was identified during an interview and record review, revealing that the facility did not have a qualified healthcare professional complete the Level I PASRR for R19. The resident was admitted with diagnoses including major depressive disorder, anxiety disorder, and seizures, and was prescribed medications such as sertraline, olanzapine, and venlafaxine for mental health conditions. However, the PASRR completed by the Admissions Coordinator, V26, inaccurately reported that there were no mental health diagnoses or medications, which was contrary to the resident's medical records. V26, who holds an associate degree in medical coding and is not a nurse or social worker, was responsible for completing the Level I PASRR. She admitted to not including R19's mental health medications in the PASRR submission, following instructions from a previous admissions coordinator. The facility's policy requires that PASRR submissions be completed by qualified healthcare professionals, such as nurses or social workers, and that all relevant diagnoses and medications be accurately reported. The inaccurate submission led to a Level I outcome indicating no need for a Level II PASRR, despite the presence of serious mental health conditions.
Failure to Revise Care Plan for Fall Prevention
Penalty
Summary
The facility failed to timely revise the care plan with specific fall-prevention interventions for a cognitively impaired resident who required staff assistance. The resident, who had a history of repeated falls and was diagnosed with dementia, psychosis, anxiety disorder, major depressive disorder, and other conditions, experienced a fall on March 15, 2025, while being transported in a wheelchair without leg rests. This incident resulted in a bruise on the resident's forehead and face, and the resident was subsequently transported to the hospital for evaluation. Despite the resident's history of falls, the care plan was not updated with specific interventions to prevent future incidents, and no root cause analysis was conducted after each fall to address contributing factors. The Acting Director of Nursing confirmed that the fall on March 15, 2025, did not prompt a care plan revision, and no targeted prevention measures were implemented, highlighting a deficiency in the facility's response to the resident's fall risk.
Failure to Provide Restorative Services to a Resident
Penalty
Summary
The facility failed to provide restorative services to a resident as per its policy. A resident expressed that he did not receive restorative therapy, which he desired. A Licensed Practical Nurse confirmed not having seen the resident receiving any restorative therapy. The Rehabilitation Manager stated that the resident was not receiving skilled therapy services because he was evaluated to be at his prior level of functioning during the initial assessment. However, the therapy department recommended that the resident receive restorative therapy, and a referral was made to the Director of Nursing. The Director of Nursing was unaware of the referral and confirmed that the resident was not receiving restorative therapy. It was also noted that when the facility was understaffed, Certified Nursing Assistants did not provide restorative therapy. The facility's policy requires all residents to be screened for restorative care under specific conditions, including termination from active therapy, significant change in status, quarterly assessment progress, and nursing referral.
Failure to Provide Adequate Nail Care to Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care to residents who are dependent on staff assistance with Activities of Daily Living (ADLs). Three residents, identified as R44, R47, and R485, were observed with long, untrimmed fingernails, some with debris underneath, and others embedded into their palms due to contracted hands. These observations were made over multiple days, indicating a lack of routine nail care as required by the facility's policy. The policy mandates that nursing staff or qualified activity team members perform routine nail care, including daily cleaning and regular trimming, to prevent infections and skin problems. Resident R485, who was moderately cognitively impaired and dependent on staff for personal hygiene, was observed with long, dirty fingernails and expressed a desire for nail care. Similarly, residents R44 and R47, both with self-care deficits due to left hemiplegia and other medical conditions, were observed with long, jagged fingernails embedded into their palms. Despite their care plans indicating a need for total assistance with hygiene and personal care, these residents did not receive the necessary nail care, compromising their comfort and hygiene.
Failure to Provide Interventions for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide necessary interventions and positioning devices for two residents with limited range of motion, leading to further decrease in their range of motion and contractures. One resident, admitted with multiple diagnoses including hemiplegia and hemiparesis, was found without a splint for her contracted left hand, despite her care plan identifying limited range of motion. The care plan lacked specific interventions for passive or active assisted range of motion exercises and did not specify the use of a positioning device to prevent further contractures. Another resident, also with hemiplegia and hemiparesis, was found with a flexion contracture in her left hand and stated she was supposed to have a splint, which was not provided. Her occupational therapy evaluation noted a contracture but indicated that nursing was managing it, yet her care plan did not address interventions for her decreased range of motion or the need for a positioning device. The facility's policy on resident mobility and range of motion was not followed, as it required treatment and services to prevent further decrease in range of motion and the provision of necessary equipment.
Lack of Justification for Indwelling Catheter Use
Penalty
Summary
The facility failed to document the justification for the continued use of an indwelling urinary catheter for a resident who experienced a urinary tract infection. The resident, who was admitted with multiple diagnoses including chronic atrial fibrillation, morbid obesity, sepsis, and benign prostatic hyperplasia, was moderately cognitively impaired and dependent on staff for various activities. Despite having an indwelling urinary catheter, the resident's admission assessment did not identify its use, and the physician's order lacked a reason for the catheter or instructions for its care and maintenance. The resident's care plan did not include the presence of the indwelling catheter or interventions for infection prevention. A urine culture revealed a significant infection, and the resident received antibiotic treatment. The Acting Director of Nursing acknowledged the absence of documentation or evaluation justifying the catheter's continued use and was uncertain about the reason for its use. Additionally, there was no facility policy regarding the evaluation for the justification of indwelling urinary catheter use.
Failure to Develop Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident diagnosed with dementia, specifically Alzheimer's disease. The resident, who was admitted with multiple diagnoses including Alzheimer's, ventricular tachycardia, and arthritis, was found to have moderate cognitive impairment according to the MDS dated March 7, 2025. However, as of April 9, 2025, the resident's care plan did not include any specific interventions or considerations for dementia care. The Social Services Director acknowledged that the comprehensive care plan, completed on March 14, 2025, should have addressed the resident's Alzheimer's diagnosis and included a tailored care plan for dementia care needs.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident's non-pressure wounds as ordered by the wound physician. The resident, identified as R2, had multiple wounds including a non-pressure trauma wound on the left first toe, a wound on the right lower lateral leg, and skin tears on the left leg and hip. The wound physician had prescribed specific treatments for these wounds, including the use of xeroform gauze and gauze roll daily. However, the Treatment Administration Record (TAR) for January and February did not reflect these orders, and the prescribed treatments were not administered as required. On observation, R2's left first toe was found without a dressing, contrary to the physician's orders. Additionally, the wound on the right lower lateral leg was treated with silver sulfadiazine and calcium alginate instead of the prescribed xeroform gauze. The skin tears on the left leg and hip also lacked documented treatment orders in the TAR. Interviews with the wound physician and the wound LPN confirmed that the treatment plans were not followed, highlighting a failure in the facility's adherence to the prescribed wound care protocols.
Failure to Implement Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that ordered pressure ulcer treatments were in place and properly implemented for three residents with pressure ulcers. For Resident 2, the treatment plan for a Stage 4 pressure ulcer on the left heel was not followed as prescribed by the wound physician. The treatment administration record (TAR) did not reflect the physician's orders for xeroform gauze or silver sulfadiazine, and the wound care provided did not match the prescribed treatment. Additionally, the treatment for a deep tissue injury on the right ankle was not consistent with the physician's orders, as the TAR did not document the required daily application of xeroform and gauze roll. Resident 3's care was also deficient, as the wound care provided did not align with the physician's treatment plan for unstageable deep tissue injuries on the buttocks. The TAR only documented the use of bordered foam dressings, while the physician's plan called for skin prep and gauze island with border. During an observation, the resident's wounds were found without dressings, and the care provided did not match the prescribed treatment. For Resident 1, the facility failed to update the TAR to reflect changes in the treatment plan for an unstageable pressure injury on the left heel. The physician's orders for betadine and alginate calcium with silver were not documented in the TAR, and the care provided did not follow the updated treatment plan. The facility's policy on pressure injury prevention and management was not adhered to, as the wound consultant's recommendations were not accurately reflected in the residents' medical records.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during wound care for a resident under strict contact isolation for MRSA and C. Striatum. A Licensed Practical Nurse (LPN) brought the treatment cart into the resident's isolation room, which is against the facility's infection control policy. During the dressing change, the LPN did not change gloves or perform hand hygiene after handling soiled dressings and before accessing the treatment cart for additional supplies. This action risked cross-contamination and the spread of infection. The Infection Preventionist confirmed that treatment carts should not enter isolation rooms and that supplies brought into such rooms should remain there for use only with the specific resident. The facility's hand hygiene policy mandates that staff perform hand hygiene when moving from a contaminated body site to a clean body site during resident care. The LPN's failure to follow these protocols during the dressing change for the resident with wound infections led to the identified deficiency.
Failure to Honor Resident's Financial Management Rights
Penalty
Summary
The facility failed to honor a resident's right to manage their financial affairs, as evidenced by the actions taken regarding the resident's Social Security payments. The resident, who has Alzheimer's disease, dementia, and other significant health conditions, was admitted to the facility with their spouse designated as the Power of Attorney for both care/medical and financial matters. The spouse was responsible for handling the resident's finances, including payments to the facility. However, the facility's Business Office Manager applied to become the representative payee for the resident's Social Security income without the spouse's consent, citing that the spouse was not paying the facility the required portion of the resident's income for room and board. The Business Office Manager proceeded with the application despite the spouse's disagreement, arguing that the facility had the legal right to do so after exhausting attempts to collect the owed payments. The facility's administrator acknowledged that permission should have been obtained from the family before applying for representative payee status. The application form submitted by the facility inaccurately stated that the resident did not owe any money to the facility, despite an outstanding balance of $13,266.50. The facility's collection policy indicated that initiating a representative payee application was applicable for unpaid balances, but the process was not followed with the necessary consent from the resident's spouse.
Failure to Provide Safe Transfer Assistance
Penalty
Summary
The facility failed to provide safe transfer assistance, resulting in a resident sustaining left and right femoral fractures. The resident, who had a medical history including right and left periprosthetic fractures around both artificial knee joints, dementia, and physical disability, was bedbound and unable to bear weight. On the day of the incident, a CNA performed a pivot transfer without using a gait belt, which caused the resident to become dead weight and led to swelling in both knees. Subsequent X-rays confirmed fractures in both legs. The care plan for the resident was incomplete and did not specify individualized transfer needs. The Director of Nursing acknowledged that the care plan was not updated, which contributed to the lack of proper transfer instructions. The Physical Therapist emphasized that a gait belt should always be used for transfers, and the Medical Director suggested that the injuries might have resulted from a forceful transfer. The facility's policy on mobility assistance was not followed, leading to the resident's injuries.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain resident rooms in a clean and sanitary manner for four of the seven residents reviewed. Observations revealed that the bathroom shared by one resident had a full garbage container, stool in the toilet, soiled washcloths, food debris in the sink, and tissues on the floor. The family member of this resident reported that the bathroom had not been cleaned for at least two days. Additionally, other resident rooms were found with full garbage containers, food debris on the floor, and a large dried stain on a chair. These conditions were observed over several hours on the same day. Interviews with staff revealed that the facility had only two housekeepers on the day shift and none on the evening or night shifts, leading to some rooms not being cleaned daily as required. The housekeeper interviewed had only been working at the facility for three weeks and admitted that he sometimes could not complete all his assigned tasks. The facility's administrator acknowledged receiving complaints about the cleanliness of rooms and confirmed that each occupied room was supposed to be cleaned daily. The facility's policy and housekeeping checklist also mandated daily cleaning and disinfecting of resident rooms and bathrooms.
Failure to Provide Adequate Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents who required staff assistance for toileting and incontinence care. Resident R2, who was dependent on staff for toileting and incontinent of urine and stool, was found in bed with a saturated brief and complained of pain in her buttocks. Despite her complaints, staff members V8 and V9 did not change her soiled brief immediately and left her in the same condition. R2 remained in the soiled brief for over an hour before V8 CNA finally changed it, revealing that her buttocks and vaginal area were bright red. Resident R3, who was cognitively impaired due to a cerebral vascular accident and cerebral hemorrhage, was also dependent on staff for toileting and incontinence care. R3 was found in bed with a saturated brief that had leaked urine onto the bed sheet. R3's family member, V10, expressed frustration over the lack of care, stating that R3 was often found dirty and wet. V8 CNA confirmed that no care had been provided to R3 that day until the observation. The Director of Nursing (V2) stated that incontinence care should be provided every two hours, but this standard was not met for R2 and R3.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Downers Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beacon Hill | 1.3 mi | ★★★★★ | 0 | 0 |
| Bella Terra Lombard | 1.6 mi | ★★★★★ | 3 | 0 |
| Alta Rehab At Oak Brook | 2.8 mi | ★★★★★ | 6 | 0 |
| Oakwood Rehab And Nursing Center | 3 mi | ★★★★★ | 14 | 0 |
| Burgess Square Healthcare Ctr | 3.6 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.