Inspection·January 23, 2026

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify, assess, and initiate treatment orders for an acquired pressure injury upon identification. This failure resulted in R3 developing an unstageable left ischium pressure ulcer. This applies to 1 of 7 residents (R3) reviewed unstageable for pressure ulcers The findings include: R3's face sheet shows he was admitted to the facility on [DATE] with diagnoses including quadriplegia, personal history of traumatic brain injury, encounter for attention to gastrostomy, epilepsy and neuromuscular dysfunction of bladder. R3'S Braden Scale assessment dated [DATE] shows he was at moderate risk for developing pressure. R3's Braden Scale assessment shows on 10/24/25 he was a HIGH RISK for developing pressure. R3's EHR (Electronic Health Records) shows he had a facility acquired stage 2 ischium pressure ulcer identified on 9/10/25 and healed on 9/23/25. R3'S Physician Order Sheets dated through January 2026 shows orders dated 9/10/25 for wedge cushion and low air loss mattress. The P.O.S. shows he was admitted to hospice in June 2025. R3's Wound Notes by V4 (Wound Nurse) dated 12/18/25 shows left ischium deep tissue injury measuring 12 cm (centimeters) x 9.0 cm), deep [NAME] 70%, blood filled blister 30%, moderate amount of serosanguineous drainage. Peri wound criteria: erythema, maceration, bogginess. On 1/21/26 at 2:40 PM, V9 (Nurse Practitioner-Wound) said R3 had multiple risk factors for developing wounds. R3 was totally dependent on staff for all cares and had a history of wounds prior that healed. Sometimes the wounds can progressively get worse if the area is not off-loaded and not repositioned frequently. If they were assessing R3's skin it should have been non-blanchable prior to the skin being deep maroon. It's not unusual for a deep tissue injury to open because of the necrotic tissue in the wound. R3's deep tissue injury opened to an unstageable left ischium pressure wound. On 1/22/26 at 8:02 AM, V7 (Registered Nurse-RN) said R3 is non-verbal, totally dependent on staff for all cares including bed mobility. On 12/17/25 she was R3's night nurse. It was reported to her by the aide, R3 had a wound on his bottom. It was reported R3's ischium was red and bleeding. V7 said she did not assess the wound or document in the resident's medical record the wound. She notified V4 (Wound Nurse) in the morning about R3's wound. Usually, we report the wounds to the wound nurse, and she will assess the wound. On 1/21/26 at 10:28 AM, V4 (Wound Nurse) said any new wounds should be reported to me. She takes pictures of the wound, assesses the wound, notifies the physician and family, and obtains treatment orders. On 12/18/25, she was notified about R3's left ischium wound by the aide. R3 had a large deep tissue injury measuring 12cm x 9cm, it was bad when she assessed the wound. There was no dressing on his ischium. It seemed strange there was no wound on 12/16/25 when V8 (Wound Nurse) said she checked his skin. It seems like a very small amount of time for the wound to get that bad. The wound should have been identified prior to it being a large maroon area on his ischium. She confirmed nursing did not report the wound to her; and the aide notified her. R3 is totally dependent on staff, non-verbal resident, he is a quadriplegic from a motorcycle accident a year ago. R3 was at great risk for developing pressure to that area, he had a Residents Affected - Few (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 3 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 01/23/2026 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)