The Pearl of Downers Grove
3450 Saratoga Avenue · Downers Grove, IL · 60515 · 6309692900
145 certified beds For profit - Corporation Chain: Pearl Healthcare
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- 3 citations involved actual harm to residents.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
78% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 3.61 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.77 | 0.55–0.75 |
| Weekend hours / resident-day | 3.41 | ≈ weekday level |
| Nursing turnover / year | 78% | median 45% |
| Fines (3-yr window) | 1 · $30,794 |
Inspection citations (57 in the current record)
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Potential for harm · D January 23, 2026 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected February 5, 2026 · Quality of Life and Care
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Potential for harm · D January 23, 2026 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected February 5, 2026 · Quality of Life and Care
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Actual harm · G April 14, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected April 30, 2025 · Quality of Life and Care
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Actual harm · G April 14, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 30, 2025 · Quality of Life and Care
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Potential for harm · F 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.
Corrected April 30, 2025 · Resident Rights
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Potential for harm · F April 14, 2025
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected April 30, 2025 · Resident Rights
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Potential for harm · D April 14, 2025
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected April 30, 2025 · Resident Assessment and Care Planning
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Potential for harm · E April 14, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected May 1, 2025 · Resident Assessment and Care Planning
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Potential for harm · D April 14, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected April 30, 2025 · Resident Assessment and Care Planning
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Potential for harm · D April 14, 2025
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected April 30, 2025 · Quality of Life and Care
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Potential for harm · D April 14, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected April 30, 2025 · Quality of Life and Care
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Potential for harm · D April 14, 2025
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected April 30, 2025 · Quality of Life and Care
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Potential for harm · D April 14, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected April 30, 2025 · Quality of Life and Care
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Potential for harm · F April 14, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected April 30, 2025 · Nursing and Physician Services
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Potential for harm · D April 14, 2025
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected April 30, 2025 · Quality of Life and Care
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Potential for harm · D 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.
Corrected April 30, 2025 · Pharmacy Service
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Potential for harm · F April 14, 2025
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected April 30, 2025 · Nutrition and Dietary
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Potential for harm · F April 14, 2025
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected April 30, 2025 · Nutrition and Dietary
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Potential for harm · F April 14, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 30, 2025 · Nutrition and Dietary
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Potential for harm · F April 14, 2025
Provide and implement an infection prevention and control program.
Corrected April 30, 2025 · Infection Control
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Potential for harm · F April 14, 2025
Implement a program that monitors antibiotic use.
Corrected April 30, 2025 · Infection Control
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Potential for harm · D February 24, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 24, 2025 · Quality of Life and Care
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Potential for harm · D February 24, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 26, 2025 · Quality of Life and Care
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Potential for harm · D February 24, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected March 24, 2025 · Infection Control
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Potential for harm · D October 1, 2024 · found via complaint
Honor the resident's right to manage his or her financial affairs.
Corrected November 15, 2024 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| April 14, 2025 | Fine | $30,794 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145657 · certified since August 22, 1989. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.