Overall sentiment is highly mixed and polarized: many reviewers praise individual staff members, therapy outcomes, and aspects of the facility culture, while a substantial number report serious operational and quality concerns. The strongest and most consistent positives are related to the rehabilitation/therapy program and specific staff who are described as caring, proactive, and effective. Multiple families credit the therapy team and nurses with enabling safe discharges home and with making residents more independent. Admissions staff, several named employees, and at least one administrator (Leonard Koenig) receive repeated praise for compassion, responsiveness, and improvements over time. Activity programming, accessible communal spaces (courtyard, family seating), and individualized activity planning are also noted as strengths in many reviews. Several reviewers describe a home-like, family-oriented atmosphere and say their loved ones felt supported by staff.
However, a recurring and prominent theme across many reviews is chronic understaffing—especially at night and on weekends—which manifests as long waits for assistance, delayed toileting, unresponsiveness to call lights, and inadequate supervision. These staffing gaps lead to multiple concrete negative outcomes reported by families: residents left in urine or not taken to the bathroom for extended periods, delays or omissions in medication administration, missed vitals, inadequate assistance with feeding, and even incidents of resident injury. The presence of agency aides and high staff turnover compounds concerns, with frequent comments about staff appearing overworked, tired, or unwilling to help. Several reviewers explicitly state they would not consider The Pearl of Downers Grove suitable for long-term care because of these systemic staffing and supervision issues, even when short-term rehab care appeared effective.
Facility upkeep and cleanliness are described inconsistently. On tour and in many reports the building and public areas look clean; housekeeping and maintenance staff are praised by some families. Conversely, other reviewers document troubling maintenance and hygiene problems: rooms not cleaned, broken furniture, holes in drywall, plugged toilets, overflowing garbage, rusted safety handles, and even reports of a fly on a sandwich. These mixed reports suggest variability across units and time—some areas and shifts are well maintained while others fall short. Infection control lapses were also reported (staff not wearing masks, multiple COVID cases), heightening concerns about safety during the pandemic and beyond.
Dining and food quality are also mixed. Some reviewers praise texture-modified meals, dessert and beverage options, and particular meals, while others describe institutional fare, poor holiday meals, and at least one reviewer saying a meal was "disgustingly served." Staffing pressures appear to affect dining assistance; several accounts note residents not helped to eat or left unassisted in the dining room, and one reviewer described a freezing dining room where care was lacking.
Communication, documentation, and management consistency are recurring problem areas. Multiple reviews mention missing or withheld discharge paperwork, lack of a clear care plan or medication list on transition, refusal to provide home-health contacts, and poor coordination around occupant orientation. Several families experienced transportation failures and scheduling miscommunications (orientation dates, doctor rides, DMV rides), occasionally with unexpected cash demands. While there are accounts of accessible, responsive management and notable improvements under certain administrators, there are also strong reports of "terrible management," lack of security, and blame-shifting by staff when incidents occur. This split suggests recent management changes may have improved conditions for some families but that issues persist in operational areas.
Safety concerns appear in multiple detailed anecdotes: refusal to permit bed rails citing legality while offering insufficient alternatives, inadequate mats, a resident injury resulting in bleeding, and reports that staff sometimes leave early or are not present on shift. These are serious red flags for families considering long-term placement, especially for residents with mobility or cognitive impairments.
Patterns to note for decision-makers and families: The Pearl frequently receives strong endorsements for short-term rehabilitation and for individual staff members who provide excellent, compassionate care. If the primary need is intensive short-term therapy, many reviewers had positive outcomes. For long-term custodial care, however, there are repeated reports of unmet basic needs (toileting, feeding, supervision) and safety/cleanliness problems that should give pause. Experiences seem to vary by unit, shift, and time; several reviewers explicitly say care has improved, while others describe ongoing, unresolved issues.
Recommendations based on the reviews: prospective families should ask specific, verifiable questions before placement—current nurse/CNA staffing ratios (including nights and weekends), average call-light response times, policies on bed rails and safety equipment, documentation practices for discharge and medications, infection-control measures, and transportation policies and costs. During a tour, check the actual resident rooms, bathrooms, and dining areas during a mealtime and ask to speak with therapy staff and the administrator about recent improvements. If possible, get recent references from families whose loved ones received long-term care (not only rehab) and verify whether promised care plans, discharge paperwork, and home-health contacts are provided in writing. Finally, expect variability: some residents and families report excellent, even life-saving care and a supportive environment, while others report serious lapses that led to distress and unsafe conditions.
