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The Pearl of Downers Grove

3450 Saratoga Avenue, Downers Grove, IL 60515 · Du Page County · (630) 969-2900

145 certified beds, about 93 residents a day · For profit - Corporation · Medicare and Medicaid since 1989

Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
2 of 5
Staffing
1 of 5
Quality measures
2 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 145657 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on April 14, 2025, inspectors cited 19 health deficiencies (the Illinois average is 12.6, the national average 9.2).

Of 56 health citations since March 2023, 3 were rated as actual harm or immediate jeopardy to residents.

CMS lists 1 fine totaling $30,794 in the last three years; the largest was $30,794, and the latest is dated April 14, 2025.

Nurses and nurse aides worked 3.60 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 0.82 of those hours.

64.9% of nursing staff left within the year CMS measured (Illinois average 44.5%).

CMS links it to Pearl Healthcare, an affiliated group of 15 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 56 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
34D
10E
9F
Potential for minimal harm
0A
0B
0C
July 9, 2026Complaint inspection · 1 citation
  1. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 14, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision and implement identified fall prevention interventions for a newly admitted resident with a recent femur fracture and history of falls. This applies to 1 (R1) of 3 residents reviewed for accidents and supervision.
May 17, 2026Complaint inspection · 1 citation
  1. E
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 19, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to render appropriate catheter care for residents at risk for urinary infections. This applies to 4 of 4 (R1-R4) residents reviewed for urinary catheters.
January 23, 2026Complaint inspection · 2 citations
  1. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 5, 2026
    Inspectors wroteBased 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
  2. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 5, 2026
    Inspectors wroteBased on observation, interview, and record review the facility to provide care and services and failed to maintain the catheter below the level of the bladder for a resident with an indwelling urinary catheter. This applies to 1 of 3 residents (R1) reviewed for indwelling catheters in the sample of 7.
April 14, 2025Standard inspection · 19 citations
  1. G
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased 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.
  2. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe wheelchair transport for a cognitively impaired resident (R34) that required staff assistance. As a result, R34 sustained pain and significant bruising to the right side of the face, forehead and orbital area to the right eye. This applies to 1 of 1 resident (R34) reviewed for fall-related accidents in the sample of 18.
  3. F
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on interview and record review the facility failed to follow their policy and notify the Ombudsman in writing of resident transfers and discharges to the hospital. This failure has the potential to affect all 83 residents who reside in the facility.
  4. F
    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.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on interview and record review the facility failed to ensure that bed hold notices were issued in writing to residents upon transfer to the hospital. This failure has the potential to affect all 83 residents who reside in the facility.
  5. F
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on interview and record review the facility failed to provide sufficient number of Nursing staff to ensure call lights are answered timely and assistance with ADL care is given as needed. This has the potential to affect all 83 residents who reside in the facility.
  6. F
    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.
    F801 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on interview and record review, the facility failed to employ a qualified food service manager. This applies to all 83 residents residing in the facility.
  7. F
    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.
    F803 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food to residents as per their planned and dietitian-approved facility menu and per facility policy. This applies to all 82 residents residing in the facility receiving oral diets.
  8. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene after touching soiled dishes per facility policy and failed to utilize sanitizing solution at the proper concentration to sanitize food contact services per manufacturer instructions. This applies to all 83 residents living in the facility.
  9. F
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wrote3. On April 8, 2025, between 8:28 A.M. and 9:03 A.M., V28 (Licensed Practical Nurse/LPN) had administered multiple prescribed medications to R67 via the resident's gastric tube. A posted sign outside R67's room clearly instructed staff to wear appropriate Personal Protective Equipment (PPE), including gown and gloves, due to R67's Enhanced Barrier Precautions (EBP) status, which was ordered in response to the resident's gastric tube care. Despite this posted instruction and the documented order on the April 2025 Physician Order Sheet (POS) requiring EBP, V28 failed to don the required PPE gown while administering the medications. Additionally, during the medication administration process, V28 changed soiled gloves but failed to perform hand hygiene before donning a clean pair of gloves, as required by the facility's undated Hand Hygiene policy. [...]
  10. F
    Implement a program that monitors antibiotic use.
    F881 · Infection Control · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on interview and record review, the facility failed to follow their policy for antibiotic stewardship. This applies to all 83 residents residing in the facility.
  11. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 1, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident had a comprehensive care plan that outlined each residents' care needs accurately. This applies to 4 of 18 residents (R26, R27, R29, and R59) reviewed for care plans in the sample of 18.
  12. D
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    F644 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on interview and record review, the facility failed to refer a resident with a new mental health diagnosis for a level II PASRR (Preadmission Screening and Resident Review). This applies to 1 of 2 residents (R19) reviewed for PASRR in the sample of 18.
  13. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to timely revise the care plan with specific fall-prevention interventions for a cognitively impaired resident that required staff assistance. This applies to 1 of 1 resident (R34) reviewed for fall-related accidents in a sample of 18.
  14. D
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    F676 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on interview and record review, the facility failed to provide restorative services to a resident per facility policy. This applies to 1 of 1 resident (R29) reviewed for restorative services in the sample of 18.
  15. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on observation and interview, the facility failed to provide nail care to residents who are dependent on staff assistance with ADLs (Activities of Daily Living). This applies to 3 of 3 residents (R44, R47, R485) in the sample of 18.
  16. D
    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.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide interventions, and failed to prevent further decrease in ROM (Range of Motion) and failed to provide positioning device for residents with hand contractures. This applies to 2 of 5 residents (R67 and R485) reviewed for limited range of motion in the sample of 18.
  17. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to document justification for continued use of an indwelling urinary catheter for a resident who experienced a urinary tract infection. This applies to 1 of 4 residents (R27) reviewed for catheter use in the sample of 18.
  18. D
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    F744 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan to support a resident's dementia care needs. This applies to 1 of 2 residents (R26) reviewed for dementia care in the sample of 18.
  19. D
    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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 30, 2025
    Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure a resident received psychotropic medications for a specific condition. This applies to 1 of 5 residents (R26) reviewed for unnecessary psychotropic medications in the sample of 18.
February 24, 2025Complaint inspection · 3 citations
  1. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 24, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident's non-pressure wounds received treatments as ordered by the wound physician for 1 of 3 residents (R2) reviewed for wounds in the sample of 7.
  2. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 26, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure ordered pressure ulcer treatments were in place and failed to ensure pressure ulcer treatments from the Wound Physician were implemented for 3 of 3 residents (R1, R2 and R3) reviewed for pressure ulcers in the sample of 7.
  3. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 24, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure a wound treatment cart was not brought into an isolation room to prevent cross-contamination and failed to remove gloves and perform hand hygiene during wound care to prevent the spread of infection for 1 of 3 residents (R2) reviewed for infection control in the sample of 7.
October 1, 2024Complaint inspection · 1 citation
  1. D
    Honor the resident's right to manage his or her financial affairs.
    F567 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 15, 2024
    Inspectors wroteBased on interview and record review, the facility failed to ensure resident funds were managed by the resident/spouse per the resident/spouse wishes. This applies to 1 of 3 residents (R1) reviewed for representative payee in a sample of 15.
May 4, 2024Complaint inspection · 1 citation
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 8, 2024
    Inspectors wroteBased on interview and record review, the facility failed to provide safe transfer assistance. This failure resulted in R1 sustaining left and right femoral fractures. This applies to 1 of 3 residents (R1) reviewed for safe transfers.
April 30, 2024Complaint inspection · 2 citations
  1. E
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 9, 2024
    Inspectors wroteBased 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.
  2. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 9, 2024
    Inspectors wroteBased 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.
March 25, 2024Complaint inspection · 3 citations
  1. F
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) April 16, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise/monitor and provide a safe environment for residents by not having a front desk receptionist or locking facility doors during certain hours for one day (Sunday) of the week. This applies to all 76 residents in the facility.
  2. D
    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.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 16, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to make prompt efforts to resolve a resident and their POA's concerns. This applies to 1 of 3 residents (R1) reviewed for grievances in a sample of 6.
  3. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 16, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to use resident's medications brought from home at the time of admission and verify and reconcile those medications with the physician and pharmacist. This caused R1 to be charged by the insurance company for medications that were ordered through the facility's pharmacy. The facility also failed to return the medications back to the responsible party. This applies to 1 of 3 residents (R1) reviewed for medications in sample of 6.
February 2, 2024Standard inspection · 9 citations
  1. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 27, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to provide personal ADL (Activities of daily living) care for 4 residents (R5, R19, R17, & R65) who are dependent on ADL care in a sample of 31.
  2. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 27, 2024
    Inspectors wroteBased on interview and record review, the facility failed to obtain vital information regarding residents' pacemakers and ensure that it was readily available in the resident's medical record. This applies to 4 out of 4 residents (R13, R28, R34, R54) reviewed for pacemakers in a sample of 31.
  3. E
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 27, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors related to cardiac medications, insulin, and intravenous antibiotics. This applies to 4 residents (R15, R26, R36 and R63) reviewed for medications.
  4. E
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 27, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label, contain, and store medications. This applies to 5 residents (R17, R15, R24, R16, and R49) reviewed for medication storage in a sample of 31.
  5. D
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 27, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy to a resident during incontinence care. This applies to 1 resident (R15) reviewed for incontinence care in a sample of 31.
  6. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 27, 2024
    Inspectors wroteBased on observations, interviews and record reviews, the facility failed to prevent acquired pressure ulcers from worsening and new pressure ulcers from developing for 2 residents (R19 and R65) who were reviewed for wound care in a sample of 7.
  7. D
    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.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 27, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative services or treatment to prevent a decreased range of motion for a resident admitted with a limited range of motion. This applies 1 of 5 (R7) reviewed for range of motion in a sample of 31.
  8. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 27, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to follow fall interventions for residents identified as high risk for falls. This applies to 3 of 5 (R28, R42, and R64) reviewed for falls in a sample of 31.
  9. D
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 27, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered. There were 32 opportunities with 4 errors, resulting in a 12.5% error rate. This applies to 2 (R15 and R26) of the 5 residents observed in medication pass. 1. On 1/31/24 at 9:25 AM, V14 (LPN/Licensed Practical Nurse) had finished removing and preparing medications for morning medication pass and was going into R15's room to give medications. Surveyor then counted the pills in R15's pill cup and noticed there were only 8 pills when there should have been 10 pills. The medication pass was stopped and V14 was told she was missing 2 pills. V14 then went back through each due medication again and realized she did not remove the Amiodarone 200 mg (milligram) tab or the Furosemide 20 mg tab from their pill cards and she would have missed giving them to R15. [...]
January 18, 2024Complaint inspection · 1 citation
  1. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) February 14, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to assist residents identified as needing assistance with ADLs (Activities of Daily Living). This applies to 4 of 4 residents (R1, R2, R3, R4) reviewed for ADLs in the sample of 4.
March 1, 2023Standard inspection · 13 citations
  1. E
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 24, 2023
    Inspectors wroteBased on observation, interview, and record review the facility failed to follow a dietitian's recommendation for residents with significant weight loss, failed to notify the dietitian of a resident with significant weight loss, and failed to monitor a resident's weight with significant weight loss. This applies to 4 of 9 residents (R41, R68, R17, and R67) reviewed for weight loss in the sample of 18.
  2. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 24, 2023
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff wore recommended PPE (personal protective equipment) for residents positive with COVID-19. The facility also failed to ensure staff changed their gloves and washed their hands during incontinence care to prevent the spread of infection. This applies to 12 of 18 residents (R20, R31, R36, R28, R40, R44, R64, R71, R25, R332, R333, R334, & R335) reviewed for infection control in the sample of 18.
  3. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to assist a resident in a dignified manner while providing assistance with feeding which included 1 of 18 residents (R10) reviewed for dignity in a sample of 18.
  4. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2023
    Inspectors wroteBased on observation, interview and record review the facility failed to implement orders for a resident with bilateral leg edema for 1 of 18 residents (R64) reviewed for quality of care in the sample of 18.
  5. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2023
    Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure pressure reducing interventions were in place for residents at risk for pressure injuries for 2 of 3 residents (R7, R51) reviewed for pressure in a sample of 18.
  6. D
    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.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with decreases in range of motion were assessed and interventions were implemented for 2 of 2 residents (R63 and R7) reviewed for range of motion in the sample of 18.
  7. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2023
    Inspectors wroteBased on observation, interview, and record review the facility failed to have a fall prevention intervention in place for a resident at high risk for falls for 1 of 18 residents (R39) reviewed for safety in the sample of 18.
  8. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2023
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's indwelling urinary catheter bag was kept off of the floor to prevent infections for 1 of 1 resident (R74) reviewed for catheter care in the sample of 18.
  9. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2023
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident had an order for oxygen administration and failed to ensure equipment was changed weekly for 1 of 1 resident (R179) reviewed for oxygen administration in the sample of 18.
  10. D
    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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2023
    Inspectors wroteBased on interview and record review, the facility failed to ensure as needed (PRN) psychotropic medications had a stop/duration date for 3 of 5 residents (R29, R39, and R27) reviewed for psychotropic medication in the sample of 18.
  11. D
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2023
    Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered. There were 33 opportunities with 2 errors resulting in a 6.06% error rate. This applies to 1 of 4 residents (R130) observed in the medication pass.
  12. D
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2023
    Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered. There were 33 opportunities with 2 errors resulting in a 6.06% error rate. This applies to 1 of 4 residents (R130) observed in the medication pass.
  13. D
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 24, 2023
    Inspectors wroteBased on interview and record review, the facility failed to ensure residents were offered and/or received the influenza and/or pneumococcal immunizations to 2 of 5 residents (R44 and R129) reviewed for immunizations in the sample of 18.

Fire safety inspections

30 fire safety citations on file: 5 on April 14, 2025, 10 on February 2, 2024, 15 on March 1, 2023.

Every fire safety citation30 citations
  1. F
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · April 14, 2025 · Corrected (the home has a date of correction)
  2. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · April 14, 2025 · Corrected (the home has a date of correction)
  3. F
    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
    K 521 · April 14, 2025 · Corrected (the home has a date of correction)
  4. F
    Have simulated fire drills held at unexpected times.
    K 712 · April 14, 2025 · Corrected (the home has a date of correction)
  5. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · April 14, 2025 · Corrected (the home has a date of correction)
  6. F
    Establish staff and initial training requirements.
    E 37 · February 2, 2024 · Corrected (the home has a date of correction)
  7. F
    Conduct testing and exercise requirements.
    E 39 · February 2, 2024 · Corrected (the home has a date of correction)
  8. F
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · February 2, 2024 · Corrected (the home has a date of correction)
  9. F
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · February 2, 2024 · Corrected (the home has a date of correction)
  10. F
    Have properly located and lighted "Exit" signs.
    K 293 · February 2, 2024 · Corrected (the home has a date of correction)
  11. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · February 2, 2024 · Corrected (the home has a date of correction)
  12. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · February 2, 2024 · Corrected (the home has a date of correction)
  13. F
    Install corridor and hallway doors that block smoke.
    K 363 · February 2, 2024 · Corrected (the home has a date of correction)
  14. F
    Have simulated fire drills held at unexpected times.
    K 712 · February 2, 2024 · Corrected (the home has a date of correction)
  15. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · February 2, 2024 · Corrected (the home has a date of correction)
  16. F
    Develop and maintain an Emergency Preparedness Program (EP).
    E 4 · March 1, 2023 · Corrected (the home has a date of correction)
  17. F
    Develop Emergency Preparedness policies and procedures.
    E 13 · March 1, 2023 · Corrected (the home has a date of correction)
  18. F
    Address subsistence needs for staff and patients.
    E 15 · March 1, 2023 · Corrected (the home has a date of correction)
  19. F
    Establish policies and procedures for sheltering.
    E 22 · March 1, 2023 · Corrected (the home has a date of correction)
  20. F
    Develop a communication plan.
    E 29 · March 1, 2023 · Corrected (the home has a date of correction)
  21. F
    Establish emergency prep training and testing.
    E 36 · March 1, 2023 · Corrected (the home has a date of correction)
  22. F
    Implement emergency and standby power systems.
    E 41 · March 1, 2023 · Corrected (the home has a date of correction)
  23. F
    Install a two-hour-resistant firewall separation.
    K 133 · March 1, 2023 · Corrected (the home has a date of correction)
  24. F
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · March 1, 2023 · Corrected (the home has a date of correction)
  25. F
    Have properly located and lighted "Exit" signs.
    K 293 · March 1, 2023 · Corrected (the home has a date of correction)
  26. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · March 1, 2023 · Corrected (the home has a date of correction)
  27. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · March 1, 2023 · Corrected (the home has a date of correction)
  28. F
    Have simulated fire drills held at unexpected times.
    K 712 · March 1, 2023 · Corrected (the home has a date of correction)
  29. F
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · March 1, 2023 · Corrected (the home has a date of correction)
  30. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · March 1, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
April 14, 2025Fine $30,794

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeIllinoisUnited States
All nursing staff (RN, LPN and aides)3.603.453.86
Registered nurses0.820.720.69
All nursing staff on weekends3.323.073.42
Nurse aides2.06
Licensed practical nurses0.72
Nursing staff turnover (share who left in a year)64.9%44.5%45.8%
Registered nurse turnover65.2%41.8%42.9%
Administrators who left1

CMS expects 5.09 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.71 on weekdays and 3.32 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 14.7% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.61 in April to June 2025 to 3.60 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.600.823.713.32 14.7%0 of 9093
Oct to Dec 20253.610.773.693.41 20.1%0 of 9290
Jul to Sep 20253.610.863.743.28 24.9%0 of 9282
Apr to Jun 20253.610.873.773.20 27.4%0 of 9183
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Illinois, Jan to Mar 20263.260.653.402.925.4%0.6% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.

Official wage estimates for Illinois

JobMedianMiddle halfEmployed
Illinois, all employers
CNAs (nursing assistants)$22.10$18.95 to $23.2668,640
LPNs and LVNs$36.06$30.57 to $38.2517,440
Registered nurses$46.15$38.47 to $50.94138,910
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeIllinoisUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
13.613.413.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.00.90.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.01.51.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
1.73.13.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
3.12.21.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
23.114.314.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
7.74.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
32.121.715.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
33.226.123.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
15.813.812.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
2.52.01.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
2.62.21.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for The Pearl of Downers Grove's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (54.8% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

54.8% this home

No different from the national rate

US median of homes 51.5% · Illinois: 106 better, 85 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 185 eligible stays.

Potentially preventable readmissions

10.7% this home

No different from the national rate

US median of homes 10.7% · Illinois: 2 better, 14 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 194 eligible stays.

Infections that led to a hospital stay

8.8% this home

No different from the national rate

US median of homes 7.1% · Illinois: 3 better, 10 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 96 eligible stays.

Self-care and mobility at discharge

46.5% this home

Median of homes: Illinois50.0% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 58 residents counted.

Falls with major injury

2.0% this home

Median of homes: Illinois0.3% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 98 residents counted.

New or worsened pressure ulcers

2.3% this home

Median of homes: Illinois1.5% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 98 residents counted.

Medication list given at discharge

100.0% this home

Median of homes: Illinois100.0% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 27 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: PEARL OF DOWNERS GROVE LLC. CMS links this home to Pearl Healthcare, a group of 15 nursing homes averaging 2.6 stars overall.

NameRoleTypeShareSince
Ez Holdco LLCDirect ownership interestOrganization04/10/2025
Ez Holdco LLCIndirect ownership interestOrganization04/10/2025
Hooli Holdings LLCIndirect ownership interestOrganization04/10/2025
Reg 2018 Irrevocable Trust U/a/D 1/1/18Indirect ownership interestOrganization04/10/2025
Zeffren, EitanIndirect ownership interestIndividual04/10/2025
Zeffren, EitanManaging control - governing bodyIndividual04/10/2025
Pearlstone Consulting LLCOperational/managerial controlOrganization04/10/2025
Uddin, ShahaabOperational/managerial controlIndividual04/10/2025
Williams, LisaOperational/managerial controlIndividual04/10/2025
Zeffren, EitanOperational/managerial controlIndividual04/10/2025
Ez Holdco LLCAdp of the SNFOrganization04/10/2025
Hooli Holdings LLCAdp of the SNFOrganization04/10/2025
Pearlstone Consulting LLCAdp of the SNFOrganization04/10/2025
Reg 2018 Irrevocable Trust U/a/D 1/1/18Adp of the SNFOrganization04/10/2025
Uddin, ShahaabAdp of the SNFIndividual04/10/2025
Williams, LisaAdp of the SNFIndividual04/10/2025
Zeffren, EitanAdp of the SNFIndividual04/10/2025

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 29 problems in this area, most recently on July 9, 2026: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
  2. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 8 problems in this area, most recently on April 14, 2025: "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."
  3. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 7 problems in this area, most recently on April 14, 2025: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights."
  4. What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 5 problems in this area, most recently on April 14, 2025: "Provide and implement an infection prevention and control program."
  5. How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

Other nursing homes nearby

Illinois contacts for a concern about a nursing home

These are the official offices in Illinois. NursingHomeClear cannot take or act on complaints.

Common questions

What is The Pearl of Downers Grove's Medicare star rating?
CMS rates The Pearl of Downers Grove 1 out of 5 stars overall, with 2 for health inspections, 1 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did The Pearl of Downers Grove get at its last inspection?
19 health deficiencies at the standard inspection on April 14, 2025. The Illinois average is 12.6.
Has The Pearl of Downers Grove been fined?
Yes. CMS lists 1 fine totaling $30,794 in the last three years.
Does The Pearl of Downers Grove accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns The Pearl of Downers Grove?
CMS lists 17 owners and managers, and links the home to Pearl Healthcare. Legal business name: PEARL OF DOWNERS GROVE LLC.

Sources

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