Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
Based on observation, interview and record review the facility failed to ensure resident rooms were
maintained in a clean and sanitary manner for 4 of 7 residents (R3, R6, R7, R8) reviewed for a clean,
comfortable, homelike environment in the sample of 11.
The findings include:
On 4/24/24 at 8:39 AM, V10 (Family of R3) stated, This place is a nightmare. (R3) has only been here three
days. Come look at the bathroom. V10 and this surveyor went into R3's bathroom. The garbage container,
on the floor by the sink, was full of garbage. Stool was noted in the toilet and up to the bowl of the toilet.
Soiled, damp washcloths hung from a towel bar and off the side of the sink. White, clumpy food debris was
noted in the sink. Two toothbrushes laid on the sink by the faucet. A paper towel and two wadded tissues
were on the bathroom floor. V10 stated, This place is dirty and unsanitary. The same stool was in the toilet
yesterday. The food clumps in the sink were there yesterday. (R3) shares this bathroom with his neighbor so
I assume all of these stains and things belong to him (neighbor) because (R3) doesn't really get out of bed
right now. I was here twelve hours on Monday and Tuesday with (R3). No one has come to clean his room.
Yesterday (Tuesday), I went looking for a housekeeper and couldn't find one.
On 4/24/24 at 9:25 AM, both garbage containers in R8's room were full of garbage. Food debris was noted
scattered across the floor of R8's room.
On 4/24/24 at 9:45 AM, the floor of R7's room had tissues and food debris on the floor by R7's bed.
On 4/24/24 at 9:50 AM, R6 was seated in a chair in her room. A large, dried, dark brown stain was noted
down one of the sides of R6's chair. Food debris was noted on the floor by R6's bed.
On 4/24/24 at 10:47 AM, V7 Housekeeper stated he just started working as a housekeeper at the facility
three weeks ago. V7 stated he was instructed to clean each resident room, daily, on his assigned hall but,
some days I just can't get all of my work done. Sometimes, all of the rooms don't get cleaned. V7 stated the
facility had two housekeepers on the day shift, seven days a week, but no housekeeper on the evening or
night shifts.
On 4/24/24 at 1:06 PM, V1 Administrator stated she had received a few recent complaints about rooms
needing to be cleaned. V1 stated each occupied resident room is to be cleaned once a day by
housekeeping.
The facility's Cleaning and Disinfecting Environmental Services policy (undated) showed,
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
145657
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145657
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pearl of Downers Grove
3450 Saratoga Avenue
Downers Grove, IL 60515
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Environmental surfaces will be cleaned and disinfected according to CDC (Centers for Disease Control)
recommendations for disinfection of healthcare facilities and OSHA (Occupational Safety and Health
Administration) bloodborne pathogens standard .
The facility's Housekeeping checklist (undated) showed each resident room was to be cleaned daily which
included sweeping and mopping the floor, emptying trash, cleaning all furniture, and disinfecting/cleaning
the bathroom.
Event ID:
Facility ID:
145657
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145657
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pearl of Downers Grove
3450 Saratoga Avenue
Downers Grove, IL 60515
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to provide ADL (activities of daily living)
assistance to residents that required staff assistance for toileting/incontinence care for 2 of 3 residents (R2,
R3) reviewed for activities of daily living in the sample of 11.
Residents Affected - Few
The findings include:
1. R2's resident assessment dated [DATE] showed R2 was dependent on staff for toileting/incontinence
care. The assessment showed R2 was incontinent of urine and stool.
On 4/24/24 at 8:04 AM, R2 was in bed, dressed in a hospital gown. An odor of urine was noted in the room.
R2 stated, I think I might be wet. I don't get up to the toilet. I just go in my brief. R2 stated her incontinence
brief was last changed at 4:30 AM that morning. R2 complained of pain to her buttocks. At 8:25 AM, V8
Certified Nursing Assistant (CNA) and V9 Licensed Practical Nurse (LPN) entered R2's room to check R2's
buttocks due to her complaint of pain to that area. V8 and V9 repositioned R2 on her side and pulled down
R2's brief. R2's brief was saturated with dark yellow urine. R2's buttocks and vaginal area were bright red.
V8 stated, No, it doesn't look like she has any wounds (to R2's buttocks). V8 and V9 repositioned R2 back
onto the soiled brief and secured the brief in place. As V8 and V9 were walking out of R2's room, R2 stated
out loud, Isn't someone going to change me? No response was noted from V8 or V9.
On 4/24/24 at 9:30 AM, R2 remained in bed, lying on her back. R2 stated, No one has been in to change
me. I'm still wet.
On 4/24/24 at 9:35 AM, V8 CNA changed R2's soiled brief and provided her with incontinence care. R2's
buttocks and vaginal area remained bright red in color.
2. R3's admission Evaluation dated 4/22/24 showed R3 was cognitively impaired to due his diagnoses of
CVA (cerebral vascular accident) and cerebral hemorrhage. The evaluation showed R2 was incontinent of
urine and stool. R3 was dependent on staff for toileting/incontinence care.
On 4/24/24 at 8:39 AM, R3 was asleep in bed. V10 (Family of R3) and V8 CNA were at R3's bedside. V8
CNA stated she had not done cares at all on (R3) yet today. V10 stated, When I got here yesterday, (R3)
still had the same clothes on that he was wearing the day before. He was so wet with urine that his brief
had leaked, and his bedding was wet. It's to the point that I just expect (R3) to be dirty and wet when I get
here everyday. I have to come daily if I expect anything to get done. At 8:48 AM, V8 CNA and V11 CNA
changed R3's incontinence brief and provided him with incontinence care. R3's incontinence brief was
saturated with urine and a large amount of stool. Urine, from R3's brief, had leaked onto R3's bed sheet.
V10 (Family of R3) looked at the urine on R3's bed sheet and stated, Why am I not surprised by this?
On 4/24/24 at 12:21 PM, V2 (Director of Nursing) stated incontinence care should be provided every two
hours to residents that require assistance with toileting/incontinence care.
The facility's Activities of Daily Living (ADLs) policy (undated) showed, Residents will be provided with care,
treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily
living (ADLs). Residents who are unable to carry out activities of daily
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145657
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145657
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Pearl of Downers Grove
3450 Saratoga Avenue
Downers Grove, IL 60515
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
living independently will receive the services necessary to maintain good nutrition, grooming and personal
and oral hygiene .
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145657
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F584 - Safe Environment
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.
FAQ · About this visit
Common questions about this visit
What happened during the April 30, 2024 survey of THE PEARL OF DOWNERS GROVE?
This was a inspection survey of THE PEARL OF DOWNERS GROVE on April 30, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE PEARL OF DOWNERS GROVE on April 30, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.