The Pearl of Downers Grove
3450 Saratoga Avenue, Downers Grove, IL 60515 · Du Page County · 145 certified beds · avg 93 residents/day · certified since Aug 22, 1989
Part of chain: PEARL HEALTHCARE (15 facilities, chain avg rating 2.7★)
2/5
Health inspection rating (on-site)
3
Serious findings on record
$30,794
Fines, last 3 years
2.71
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Apr 14, 2025 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 30, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 14, 2025 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 30, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 4, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: May 8, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (58)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 17, 2026 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Jan 23, 2026 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jan 23, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Apr 14, 2025 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Apr 14, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 14, 2025 | F · Potential for harm, facility-wide | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Apr 14, 2025 | F · Potential for harm, facility-wide | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Apr 14, 2025 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Apr 14, 2025 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Apr 14, 2025 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Apr 14, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 14, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 14, 2025 | F · Potential for harm, facility-wide | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Apr 14, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 14, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Apr 14, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Apr 14, 2025 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Apr 14, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 14, 2025 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Apr 14, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 14, 2025 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Apr 14, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Feb 24, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 24, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Feb 24, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Oct 1, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to manage their own money and financial affairs. · from a complaint |
| May 4, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Apr 30, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Apr 30, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Mar 25, 2024 | F · Potential for harm, facility-wide | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 25, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Mar 25, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Feb 2, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 2, 2024 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 2, 2024 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Feb 2, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 2, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Feb 2, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 2, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Feb 2, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 2, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jan 18, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Aug 23, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 23, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Aug 23, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 1, 2023 | E · Potential for harm, repeated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Mar 1, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 1, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Mar 1, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Mar 1, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 1, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Mar 1, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 1, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Mar 1, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Mar 1, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Mar 1, 2023 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 1, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Mar 1, 2023 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (9 → 19).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 16 | 0 | E |
| 2024 | 17 | 1 | G ▲ |
| 2025 | 22 | 2 | G ▲ |
| 2026 | 3 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $30,794.
| Date | Type | Amount / length |
|---|---|---|
| Apr 14, 2025 | Fine | $30,794 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.71 | 2.99 | 3.95 | top 47% in Illinois; bottom 6% in the U.S. |
| Registered Nurse hours | 0.62 | 0.63 | 0.69 | top 34% in Illinois; top 46% in the U.S. |
| Weekend total nurse staffing | 2.51 | 2.67 | 3.50 | top 43% in Illinois; bottom 9% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.70 | 0.56 | 0.48 | top 24% in Illinois; top 16% in the U.S. |
| Total nursing staff turnover (%) | 64.9 | 44.5 | 45.8 | bottom 8% in Illinois; bottom 10% in the U.S. |
| RN turnover (%) | 65.2 | 41.8 | 42.9 | bottom 15% in Illinois; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.60, RN 0.82, weekend 3.32. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 1/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ez Holdco LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 04/10/2025 |
| Ez Holdco LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/10/2025 |
| Hooli Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/10/2025 |
| Reg 2018 Irrevocable Trust U/A/D 1/1/18 | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/10/2025 |
| Zeffren, Eitan | Individual | Indirect Ownership Interest | NOT APPLICABLE | 04/10/2025 |
| Ez Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/10/2025 |
| Hooli Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/10/2025 |
| Pearlstone Consulting LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/10/2025 |
| Pearlstone Consulting LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/10/2025 |
| Reg 2018 Irrevocable Trust U/A/D 1/1/18 | Organization | ADP of the SNF | NOT APPLICABLE | 04/10/2025 |
| Uddin, Shahaab | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/10/2025 |
| Uddin, Shahaab | Individual | ADP of the SNF | NOT APPLICABLE | 04/10/2025 |
| Williams, Lisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/10/2025 |
| Williams, Lisa | Individual | ADP of the SNF | NOT APPLICABLE | 04/10/2025 |
| Zeffren, Eitan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/10/2025 |
| Zeffren, Eitan | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/10/2025 |
| Zeffren, Eitan | Individual | ADP of the SNF | NOT APPLICABLE | 04/10/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "If you ever planned to discharge or transfer my family member, how much written notice would we receive and how could we appeal?"
- "If my family member goes to the hospital, how long will you hold their bed, and will we get that in writing?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Beacon Hill | 1.3 mi | Lombard, IL | ★★★★★ | 4/5 | |
| Bella Terra Lombard | 1.6 mi | Lombard, IL | ★★★★☆ | 3/5 | |
| Alta Rehab at Oak Brook | 2.8 mi | Oak Brook, IL | ★★☆☆☆ | 2/5 | |
| Oakwood Rehab and Nursing Center | 3.0 mi | Westmont, IL | ★☆☆☆☆ | 1/5 | abuse |
| Burgess Square Healthcare Ctr | 3.6 mi | Westmont, IL | ★★★★☆ | 3/5 | |
| Pearl of Hinsdale, the | 4.0 mi | Hinsdale, IL | ★★★★☆ | 4/5 | |
| Oak Trace | 4.2 mi | Downers Grove, IL | ★★★★★ | 4/5 | |
| Bella Terra Elmhurst | 4.2 mi | Elmhurst, IL | ★★★★☆ | 4/5 | |
| Bria of Westmont | 4.3 mi | Westmont, IL | ★☆☆☆☆ | 1/5 | |
| The Commons at Lisle Creek Estates | 4.4 mi | Lisle, IL | ★★★★☆ | 4/5 | |
| Park Place Christian Community | 4.9 mi | Elmhurst, IL | ★★★★★ | 4/5 | |
| Thrive of Lisle | 5.3 mi | Lisle, IL | ★★★★☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 145657.