The Pearl of Downers Grove

In the surveyor’s words

From the most serious findings on record at The Pearl of Downers Grove, in the surveyor’s own words.

• Immediate jeopardy, patternF600Mar 17, 2023

  Based on interview and record review the facility failed to keep residents free from sexual abuse and exploitation by V3 (Former Housekeeping Staff). R1, R3, R4 and R5 had sexually explicit videos and photographs taken of them by V3 in October 2022 and November of 2022. The facility failed to conduct a comprehensive investigation of these incidents and report these to the local police. The facility failed to ensure that residents exposed to abuse were kept safe for any additional abuse and take measures to ensure that additional residents were not exposed to abuse. This failure resulted in V3 taking sexually explicit videos and photographs involving R1, R3, R4, and R5 that was reported to the facility by V11 (Police Detective) on February 15, 2023. […]

• Immediate jeopardy, patternF607Mar 17, 2023

  Based on interview and record review, the facility failed to implement their policy to thoroughly investigate an allegation of employee to resident sexual abuse. This failure resulted in, facility staff identifying R1, R3, R4, and R5 as residents explicitly photographed by V3 (Former Housekeeping Staff) when V11 (Police Detective) came to the facility on [DATE] and reported a sexual abuse investigation into V3. The facility also had an anonymous letter sent to them, dated October 12, 2022, regarding V3 and his past history of sexual abuse in the facility. This failure resulted in V3 taking sexually explicit videos and photographs involving R1, R3, R4, and R5 that was reported to the facility by V11 (Police Detective) on February 15, 2023. […]

• Immediate jeopardy, patternF610Mar 17, 2023

  Based on interview and record review, in response to allegations of abuse, the facility failed to thoroughly investigate the alleged abuse and prevent further abuse or mistreatment from occurring. The facility failed to validate sexual abuse and implement training after an allegation of sexual abuse. This failure resulted in, facility staff identifying R1, R3, R4, and R5 as residents explicitly photographed by V3 (Former Housekeeping Staff) when V11 (Police Detective) came to the facility on [DATE], and reported a sexual abuse investigation into V3. The facility also had an anonymous letter sent to them, dated October 12, 2022, regarding V3 and his past history of sexual abuse in the facility. […]

• Immediate jeopardy, isolatedF686Apr 7, 2023

  1. Based on interview, and record review, the facility failed to ensure a resident's treatment for her stage IV pressure ulcer was completed as ordered, failed to ensure ongoing assessment and monitoring was done for the pressure ulcer, and failed to ensure the Wound Physician referral was carried out. These failures resulted in R1 being discharged to the hospital on 3/24/23 with a change in condition and a subsequent diagnosis of osteomyelitis to her stage IV pressure ulcer on her right heel. […]

• Actual harm, isolatedF686Apr 14, 2025

  Based on observation, interview, and record review, the facility failed to implement interventions to prevent and treat a pressure injury per facility policy. This failure resulted in the development of a DTI (Deep Tissue Injury) for a resident at moderate risk for the development of pressure injuries. This applies to 1 of 4 residents (R59) reviewed for pressure injuries in the sample of 18. The findings include: Face sheet, dated April 9, 2025, shows R59 was admitted to the facility on [DATE], and her diagnoses included pulmonary embolism, malignant neoplasm of bronchus or lung, weakness, diabetes, protein-calorie malnutrition, vascular dementia, congestive heart failure, chronic kidney disease, and need for assistance with personal care. […]