01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-04-14 | 22 | 2025-04-14 | 5 |
| Cycle 2 | 2024-02-02 | 13 | 2024-02-02 | 10 |
| Cycle 3 | 2023-03-01 | 23 | 2023-03-01 | 15 |
CMS CCN 1456572026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
The Pearl Of Downers Grove
3450 Saratoga Avenue · Downers Grove, IL 60515 · Du Page County
Certified beds145CMS provider file
Recent citation rows88current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
88 rows in the current release
3 rows carry G–L scope/severity codes; 0 carry J–L. 16 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-05-17 · HEALTHF0690Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-05-19 · complaint2026-01-23 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2026-02-05 · complaint2026-01-23 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-05 · complaint2025-04-14 · HEALTHF0623Severity F · widespread; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0625Severity F · widespread; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-04-14 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0676Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0688Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0725Severity F · widespread; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0744Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0801Severity F · widespread; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0803Severity F · widespread; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · HEALTHF0881Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Correction field: Deficient, Provider has date of correction · 2025-04-302025-04-14 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2025-04-282025-04-14 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-04-2903 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-04-14 | Fine | $30,794 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- EZ HOLDCO LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 04/10/2025
- EZ HOLDCO LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 04/10/2025
- HOOLI HOLDINGS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 04/10/2025
- REG 2018 IRREVOCABLE TRUST U/A/D 1/1/18Organization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 04/10/2025
- ZEFFREN, EITANIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 04/10/2025
- ZEFFREN, EITANIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/10/2025
- PEARLSTONE CONSULTING LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/10/2025
- UDDIN, SHAHAABIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/10/2025
- WILLIAMS, LISAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/10/2025
- ZEFFREN, EITANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/10/2025
- EZ HOLDCO LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/10/2025
- HOOLI HOLDINGS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/10/2025
- PEARLSTONE CONSULTING LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/10/2025
- REG 2018 IRREVOCABLE TRUST U/A/D 1/1/18Organization · ADP OF THE SNFNOT APPLICABLE · since 04/10/2025
- UDDIN, SHAHAABIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/10/2025
- WILLIAMS, LISAIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/10/2025
- ZEFFREN, EITANIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/10/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.60per resident day
RN hours0.82per resident day
Weekend nurse hours3.32per resident day
Staff turnover64.9%CMS reported field
06 / LOCAL RECORDS
Open the Downers Grove ledger →