Cycle 1
Health 2025-04-14 · Fire 2025-04-14
21 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Downers Grove, IL
The Pearl Of Downers Grove
1-star overall rating with 1-star inspections with $30,264 in total fines with 20 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
3450 Saratoga Avenue, Downers Grove, IL
(630) 969-2900
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
145
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-08-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
2.86
CMS adjusted total nurse staffing hours
Case-mix index
1.73
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
77%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,478
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.91
Baseline 21.92% · Performance 20.75% · Measure score 1.91 · Achievement 1.48 · Improvement 1.91
Healthcare-associated infections
0
Baseline 7.51% · Performance 8.75% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 65.52% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.14 hours · Performance 2.65 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.72% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 194 · Observed rate 10.82% · Lower 95% interval 7.88% |
| Discharge to community | 54.75% |
50.57%
4.2 pts better
|
No Different than the National Rate · Eligible stays 185 · Observed rate 48.65% · Lower 95% interval 47.47% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.95% |
95.27%
3.7 pts better
|
Numerator 94 · Denominator 95 |
| Falls with major injury | 2.11% |
0.77%
1.3 pts worse
|
Numerator 2 · Denominator 95 |
| Discharge self-care score | 60.71% |
53.69%
7 pts better
|
Numerator 34 · Denominator 56 |
| Discharge mobility score | 58.93% |
50.94%
8 pts better
|
Numerator 33 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 95 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.75% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 11.46% · Lower 95% interval 5.92% |
| Staff COVID-19 vaccination coverage | 1.95% |
8.2%
6.2 pts worse
|
Numerator 4 · Denominator 205 |
| Staff flu vaccination coverage | 46.34% |
42%
4.3 pts better
|
Numerator 38 · Denominator 82 |
| Discharge function score | 57.14% |
56.45%
0.7 pts better
|
Numerator 32 · Denominator 56 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 44 · Denominator 44 |
| Transfer of health information to patient | 96.55% |
96.28%
0.3 pts better
|
Numerator 28 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 15.69% |
25.2%
9.5 pts worse
|
Numerator 8 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.0
0.7 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.7 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.3
0.9 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
89.6%
3.5 pts better
|
93.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.7% · Q2 100.0% · Q3 97.0% · Q4 82.7% · 4Q avg 93.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
91.6%
5.8 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.3%
0.4 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.3% · Q3 3.0% · Q4 1.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 54.4% |
50.3%
4.1 pts worse
|
11.4%
43 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.1% · Q2 26.3% · Q3 42.1% · Q4 97.1% · 4Q avg 54.4% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
6.5%
2.5 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 6.8% · Q3 3.8% · Q4 1.8% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.1% |
18.5%
11.4 pts better
|
19.6%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 1.6% · Q3 7.0% · Q4 8.1% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.4% |
22.8%
5.6 pts worse
|
16.7%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 32.6% · Q3 32.6% · Q4 24.5% · 4Q avg 28.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.5% |
17.2%
14.3 pts worse
|
16.3%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 42.6% · 4Q avg 31.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.7% |
15.0%
6.7 pts worse
|
14.9%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 37.5% · Q3 18.9% · Q4 21.1% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.1%
0.2 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.3% |
21.3%
9 pts worse
|
19.8%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 33.7% · Q3 35.8% · Q4 24.2% · 4Q avg 30.3% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
5.2%
1.7 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.8% · Q3 8.9% · Q4 9.4% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 59.4% |
68.8%
9.4 pts worse
|
81.7%
22.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.4% · Q2 80.2% · Q3 56.5% · Q4 22.6% · 4Q avg 59.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.0% |
14.0%
5 pts better
|
12.0%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 10.4% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.0% |
2.3%
1.7 pts worse
|
1.6%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.3% · Q3 2.2% · Q4 2.8% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.4% |
63.0%
17.4 pts better
|
79.7%
0.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.7% |
26.2%
3.5 pts worse
|
23.9%
5.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.7% · Observed 35.4% · Expected 28.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-02 · Fire 2024-02-02
19 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2023-03-01 · Fire 2023-03-01
29 health deficiencies
Top issue: Quality of Life and Care (14 deficiencies)
15 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-04-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-04-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-29
F · Potential for more than minimal harm
2025-04-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-04-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-29
F · Potential for more than minimal harm
2024-02-02
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-02
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-23
F · Potential for more than minimal harm
2024-02-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-12
F · Potential for more than minimal harm
2024-02-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-28
F · Potential for more than minimal harm
2024-02-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-23
F · Potential for more than minimal harm
2023-03-01
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-01
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-01
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-01
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-01
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-01
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-01
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-01
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-01
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-01
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-14
F · Potential for more than minimal harm
2023-03-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-14
Inspection history
Recent health citations
G · Actual harm
2026-01-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-05
D · Potential for more than minimal harm
2026-01-23
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-02-05
G · Actual harm
2025-04-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-30
G · Actual harm
2025-04-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-14
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-14
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-14
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-14
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-14
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-04-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-04-14
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-14
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-14
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-14
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-04-14
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-02-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-26
D · Potential for more than minimal harm
2025-02-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-24
D · Potential for more than minimal harm
2024-10-01
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-11-15
G · Actual harm
2024-05-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-08
E · Potential for more than minimal harm
2024-04-30
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-04-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-09
F · Potential for more than minimal harm
2024-03-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-03-25
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-03-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-16
E · Potential for more than minimal harm
2024-02-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-02-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-02-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-02-02
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-02-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-02-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-02-02
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-02-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-02-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-01-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-14
D · Potential for more than minimal harm
2023-08-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-08-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-13
D · Potential for more than minimal harm
2023-05-06
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-12
G · Actual harm
2023-04-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-04-20
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-20
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-05-12
J · Immediate jeopardy
2023-04-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-04
D · Potential for more than minimal harm
2023-04-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-04
K · Immediate jeopardy
2023-03-17
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-03-24
K · Immediate jeopardy
2023-03-17
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-03-24
K · Immediate jeopardy
2023-03-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-24
F · Potential for more than minimal harm
2023-03-17
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-03-24
F · Potential for more than minimal harm
2023-03-17
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-03-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-24
E · Potential for more than minimal harm
2023-03-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-01
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-01
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-01
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-24
Penalties and ownership
What sits behind the stars
$30,264
2025-04-14
Fine
Fine · fine $30,264
Fine
Ownership
Pearlstone Consulting LLC
Operational/Managerial Control · Organization
Uddin, Shahaab
Operational/Managerial Control · Individual
Williams, Lisa
Operational/Managerial Control · Individual
Zeffren, Eitan
Operational/Managerial Control · Individual
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