The Pearl of Downers Grove
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 92 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (1/5 stars)
- Low staffing rating (1/5 stars)
- Above-median deficiencies (20 vs median 11.0)
- High staff turnover (76%)
- High RN turnover (54%)
Bottom 25% in IL · Meets national RN staffing standard · Above average staffing · Very high staff turnover · $30,264 in fines
What this means for your family
While the therapy department is highly regarded for helping patients regain mobility, the facility faces serious allegations regarding basic patient care and neglect. Families should conduct unannounced visits, specifically on weekends, and closely monitor their loved one's hygiene and medical status to ensure safety.
Google Reviews
Google Reviews
92 reviews on Google“The Pearl of Downers Grove receives highly polarized feedback, with many reviewers praising the dedicated therapy team and friendly staff, while others report severe concerns regarding patient neglect and poor communication. Families considering this facility should be aware of significant discrepancies in care quality, as some report excellent experiences while others describe dangerous lapses in hygiene and medical oversight.”
Quality Themes
Tap a score for detailsStrengths
- Dedicated and effective rehabilitation therapy team
- Clean and well-maintained facility environment
- Friendly and welcoming administrative staff
- Active and engaging resident activity programs
Concerns
- Neglect regarding basic hygiene and patient care (e.g., changing, turning, feeding) (mentioned by 4 reviewers)
- Poor communication and lack of responsiveness from management (mentioned by 3 reviewers)
- Understaffing, particularly on weekends and during off-hours (mentioned by 3 reviewers)
- Issues with discharge planning and medical transportation coordination (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 97 analyzed
How They Respond to Reviews
Questions for Your Tour
- 1Given the recent focus on staffing, what specific protocols are in place to ensure consistent care, such as hygiene assistance and turning schedules, during weekend and evening shifts?
- 2I noticed the facility has a strong reputation for rehabilitation therapy; how does that team coordinate with the nursing staff to ensure a resident's daily medical needs are met during their recovery?
- 3To address concerns regarding communication, what is the standard process for family members to receive updates on a loved one's care plan or changes in their health status?
- 4With the current activity program being a highlight, could you walk me through how you tailor these engagement opportunities for residents who may have different levels of mobility or cognitive ability?
- 5How does the facility handle the coordination of medical transportation for outside appointments, and what steps are taken to ensure these transitions are seamless for the resident?
- 6Regarding medication management, what systems do you have in place to ensure accuracy and timely administration for residents with complex health needs?
Personalized based on this facility's data
Key Review Excerpts
“My sister was wheeled in a hospital bed and 6 1/2 months later she is walking with a walker truly amazing! She definitely put in the hard work which they saw and they worked hard with her so thankful for the team.”
“My mother was left sitting in her own urine and feces — ignored. She used her nurse call button, which did not work, so she was forced to use her cell phone to call the facility for help.”
“I saw some good reviews and the tour was great. I thought my mom would be in good hands. She went in talking eating and aware. By day 5 she seemed off. By day 7 she wasn't eating and was very sleepy and out of it.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
7
measures
9
measures
1
measures
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose walking got worse
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Residents whose bladder or bowel control got worse
Residents needing more daily help over time
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Families have filed 28 complaints triggering deficiencies at this facility, with recurring problems in wound care, accident prevention, and medication management. The most serious issues involved abuse reporting failures and neglect protection in 2023, though these appear corrected. Issues with pressure ulcer care persist across multiple recent surveys, including complaints as recent as 2026, suggesting ongoing challenges in this critical area despite facility corrections.
Jan 23, 2026Complaint2
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Apr 14, 2025Routine24
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies
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.
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nutrition and Dietary Deficiencies
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.
Nutrition and Dietary Deficiencies
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.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
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.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Pharmacy Service Deficiencies
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.
Feb 24, 2025Complaint3
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Oct 1, 2024Complaint1
Resident Rights Deficiencies
Honor the resident's right to manage his or her financial affairs.
May 4, 2024Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Apr 30, 2024Complaint2
Resident Rights Deficiencies
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.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Federal Penalties
Fine
Apr 14, 2025
$30,794
Ownership & Operations
Who Operates This Facility
The Pearl of Downers Grove
for profit
Chain Affiliation
Pearl Healthcare
15 facilities nationwide
Ownership & Management
Owners
Ez Holdco LLC
Owner · Organization
Ez Holdco LLC
Owner (parent company) · Organization
Hooli Holdings LLC
Owner (parent company) · Organization
Reg 2018 Irrevocable Trust U/a/d 1/1/18
Owner (parent company) · Organization
Zeffren, Eitan
Owner (parent company)
Key personnel
Contact
Get in Touch
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References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
92 reviews from families & visitors
Official Website
Visit pearldownersgrove.com
Medicare data downloads
Original nursing home datasets
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