THE PEARL OF DOWNERS GROVE
THE PEARL OF DOWNERS GROVE is a 145-bed nursing home in DOWNERS GROVE, Illinois. CMS has certified it for Medicare and Medicaid since 1989-08-22. It averages 92.9 residents a day.
What harm was found in the violations cited at THE PEARL OF DOWNERS GROVE?
CMS lists 58 health-inspection deficiencies for THE PEARL OF DOWNERS GROVE since 2023-03-01, 45 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is G; the most recent health inspection was 2026-05-17.
| Survey date | Tag | Deficiency | Severity |
|---|---|---|---|
| 2026-05-17 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | E |
| 2026-01-23 | F0686, F0690 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D |
| 2025-04-14 | F0686, F0689 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G |
| 2025-04-14 | F0623, F0625, F0725, F0801, F0803, F0812, F0880, F0881 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. / 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. / Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / 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. / 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. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide and implement an infection prevention and control program. / Implement a program that monitors antibiotic use. | F |
| 2025-04-14 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E |
| 2025-04-14 | F0644, F0657, F0676, F0677, F0688, F0690, F0744, F0758 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. / Provide care and assistance to perform activities of daily living for any resident who is unable. / 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. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. / 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. | D |
| 2025-02-24 | F0684, F0686, F0880 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide and implement an infection prevention and control program. | D |
| 2024-10-01 | F0567 | Honor the resident's right to manage his or her financial affairs. | D |
| 2024-05-04 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G |
| 2024-04-30 | F0584 | 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. | E |
| 2024-04-30 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D |
| 2024-03-25 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | F |
| 2024-03-25 | F0585, F0755 | 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. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D |
| 2024-02-02 | F0677, F0684, F0760, F0761 | Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Ensure that residents are free from significant medication errors. / 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. | E |
| 2024-02-02 | F0583, F0686, F0688, F0689, F0759 | Keep residents' personal and medical records private and confidential. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Ensure medication error rates are not 5 percent or greater. | D |
| 2024-01-18 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E |
| 2023-08-23 | F0609, F0610, F0684 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D |
| 2023-03-01 | F0692, F0880 | Provide enough food/fluids to maintain a resident's health. / Provide and implement an infection prevention and control program. | E |
| 2023-03-01 | F0550, F0684, F0686, F0688, F0689, F0690, F0695, F0758, F0759, F0760, F0883 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Provide safe and appropriate respiratory care for a resident when needed. / 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. / Ensure medication error rates are not 5 percent or greater. / Ensure that residents are free from significant medication errors. / Develop and implement policies and procedures for flu and pneumonia vaccinations. | D |
Why was THE PEARL OF DOWNERS GROVE fined?
| Date | Type | Amount |
|---|---|---|
| 2025-04-14 | Fine | $30,794 |
How is THE PEARL OF DOWNERS GROVE staffed?
| Measure | This facility | IL average |
|---|---|---|
| Total nurse staffing hours per resident per day | 3.59593 | 3.44603 |
| Total nursing staff turnover (%) | 64.9 | 44.5 |
| Average number of residents per day | 92.9 | 95.4 |
Who owns THE PEARL OF DOWNERS GROVE, and what chain is it in?
THE PEARL OF DOWNERS GROVE is registered with CMS as For profit - Corporation, operates under the legal business name PEARL OF DOWNERS GROVE LLC and belongs to the PEARL HEALTHCARE chain.
| Role | Owner | Association date |
|---|---|---|
| DIRECT OWNERSHIP INTEREST | EZ HOLDCO LLC | since 04/10/2025 |
| INDIRECT OWNERSHIP INTEREST | EZ HOLDCO LLC, HOOLI HOLDINGS LLC, REG 2018 IRREVOCABLE TRUST U/A/D 1/1/18, ZEFFREN, EITAN | since 04/10/2025 |
| MANAGING CONTROL - GOVERNING BODY | ZEFFREN, EITAN | since 04/10/2025 |
| OPERATIONAL/MANAGERIAL CONTROL | PEARLSTONE CONSULTING LLC, UDDIN, SHAHAAB, WILLIAMS, LISA, ZEFFREN, EITAN | since 04/10/2025 |
| ADP OF THE SNF | EZ HOLDCO LLC, HOOLI HOLDINGS LLC, PEARLSTONE CONSULTING LLC, REG 2018 IRREVOCABLE TRUST U/A/D 1/1/18, UDDIN, SHAHAAB, WILLIAMS, LISA, ZEFFREN, EITAN | since 04/10/2025 |
Were you or a family member harmed at THE PEARL OF DOWNERS GROVE?