Pearl Of Elk Grove, The

Penalties

• Jun 4, 2025 — Fine ($18,915)
• Jun 4, 2025 — IDPH fine (Nursing Home Care Act) ($25,000)
• Jan 2, 2025 — IDPH fine (Nursing Home Care Act) ($2,200)
• Sep 26, 2024 — IDPH fine (Nursing Home Care Act) ($25,000)
• Sep 26, 2024 — Fine ($58,852)
• Jul 11, 2024 — IDPH fine (Nursing Home Care Act) ($2,200)
• Jul 11, 2024 — Fine ($14,307)
• Jul 11, 2024 — Payment Denial · payment denial 20 days
• Jun 14, 2024 — IDPH fine (Nursing Home Care Act) ($2,200)
• Jun 7, 2024 — Fine ($42,224)
• Jun 7, 2024 — IDPH fine (Nursing Home Care Act) ($2,200)
• Mar 26, 2024 — Fine ($9,835)
• Mar 26, 2024 — IDPH fine (Nursing Home Care Act) ($2,200)
• Dec 19, 2023 — IDPH fine (Nursing Home Care Act) ($25,000)

Inspection findings

1. Dec 19, 2025 Health · 7 findings
   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Dec 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Dec 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Dec 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Dec 26, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Dec 26, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Dec 26, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 26, 2025 · CMS health inspection

2. Jul 30, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Aug 5, 2025 · CMS health inspection

3. Jun 4, 2025 Health · 2 findings
   • Serious Scope/severity G Complaint Under dispute

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Jun 16, 2025 · CMS health inspection

   • Serious Scope/severity A

     Type A Illinois Nursing Home Care Act violation

     Type A: substantial probability of death or serious harm, or actual harm (1-129). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), 300.1210d)6), 300.3210t) and 300.3240a). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b), 300.1210d)6), and 300.3240a).

     Statement of deficiencies (PDF)

4. May 8, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected May 12, 2025 · CMS health inspection

5. Apr 1, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Apr 8, 2025 · CMS health inspection

6. Jan 15, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Jan 21, 2025 · CMS health inspection

7. Jan 2, 2025 Health · 2 findings
   • Serious Scope/severity G Complaint

     F0758 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.

     Corrected Jan 10, 2025 · CMS health inspection

   • Not serious Scope/severity B

     Type B Illinois Nursing Home Care Act violation

     Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), 300.1210c), and 300.1210d)3)6). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and 300.1210d)6).

     Statement of deficiencies (PDF)

8. Dec 17, 2024 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0585 Resident Rights Deficiencies

     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.

     Corrected Dec 20, 2024 · CMS health inspection

9. Nov 8, 2024 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Nov 14, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Nov 14, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0725 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.

     Corrected Nov 14, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Nov 14, 2024 · CMS health inspection

10. Oct 23, 2024 Health · 15 findings
    • Not serious Scope/severity D

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Dec 10, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0688 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.

      Corrected Nov 5, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Dec 10, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0758 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.

      Corrected Nov 5, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0761 Pharmacy Service Deficiencies

      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.

      Corrected Dec 10, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Nov 5, 2024 · CMS health inspection

    • Not serious Scope/severity E

      K0324 Smoke Deficiencies

      Provide properly protected cooking facilities.

      Corrected Nov 6, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0345 Smoke Deficiencies

      Have approved installation, maintenance and testing program for fire alarm systems.

      Corrected Nov 6, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0351 Smoke Deficiencies

      Install an approved automatic sprinkler system.

      Corrected Nov 6, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0363 Smoke Deficiencies

      Install corridor and hallway doors that block smoke.

      Corrected Nov 6, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0372 Smoke Deficiencies

      Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

      Corrected Nov 7, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0521 Services Deficiencies

      Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

      Corrected Nov 6, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0914 Gas, Vacuum, and Electrical Systems Deficiencies

      Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

      Corrected Nov 6, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Nov 6, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0923 Gas, Vacuum, and Electrical Systems Deficiencies

      Have proper medical gas storage and administration areas.

      Corrected Nov 6, 2024 · CMS fire safety

11. Sep 26, 2024 Health · 5 findings
    • Serious Scope/severity J Complaint

      F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

      Corrected Oct 1, 2024 · CMS health inspection

    • Serious Scope/severity L Complaint

      F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Respond appropriately to all alleged violations.

      Corrected Oct 1, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0657 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.

      Corrected Oct 1, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0712 Nursing and Physician Services Deficiencies

      Ensure that the resident and his/her doctor meet face-to-face at all required visits.

      Corrected Oct 1, 2024 · CMS health inspection

    • Serious Scope/severity A

      Type A Illinois Nursing Home Care Act violation

      Type A: substantial probability of death or serious harm, or actual harm (1-129). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), 300.1210d)6), and 300.3210t). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and 300.1210d)6).

      Statement of deficiencies (PDF)

12. Aug 20, 2024 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0658 Resident Assessment and Care Planning Deficiencies

      Ensure services provided by the nursing facility meet professional standards of quality.

      Corrected Aug 22, 2024 · CMS health inspection

13. Aug 10, 2024 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0626 Resident Rights Deficiencies

      Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

      Corrected Aug 22, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Aug 22, 2024 · CMS health inspection

14. Jul 11, 2024 Health · 2 findings
    • Serious Scope/severity G Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Jul 24, 2024 · CMS health inspection

    • Not serious Scope/severity B

      Type B Illinois Nursing Home Care Act violation

      Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), and 300.1210d)6). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and 300.1210d)6).

      Statement of deficiencies (PDF)

15. Jun 14, 2024 Health · 3 findings
    • Not serious Scope/severity D Complaint

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Jun 26, 2024 · CMS health inspection

    • Serious Scope/severity G Complaint

      F0692 Quality of Life and Care Deficiencies

      Provide enough food/fluids to maintain a resident's health.

      Corrected Jun 26, 2024 · CMS health inspection

    • Not serious Scope/severity B

      Type B Illinois Nursing Home Care Act violation

      Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), and 300.1210d)3). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b).

      Statement of deficiencies (PDF)

16. Jun 7, 2024 Health · 7 findings
    • Not serious Scope/severity F Complaint

      F0585 Resident Rights Deficiencies

      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.

      Corrected Jun 21, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Jun 21, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Jun 21, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0761 Pharmacy Service Deficiencies

      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.

      Corrected Jun 21, 2024 · CMS health inspection

    • Serious Scope/severity H Complaint

      F0803 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.

      Corrected Jun 23, 2024 · CMS health inspection

    • Serious Scope/severity H Complaint

      F0804 Nutrition and Dietary Deficiencies

      Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

      Corrected Jun 21, 2024 · CMS health inspection

    • Not serious Scope/severity B

      Type B Illinois Nursing Home Care Act violation

      Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), 300.2050a)1)2)3)4)5), 300.2050b)1)2)3)4)5)6)7)8), 300.2050c)1)A)B)C)2)A)i)ii)B)C)3), 300.2050d)1)2)3)4)5)6)7)8)9)10)11), 300.2050e), 300.2050f), and 300.2050g)1)A)B)C)2), The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b).

      Statement of deficiencies (PDF)

17. Mar 26, 2024 Health · 2 findings
    • Serious Scope/severity G Complaint

      F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

      Corrected Apr 2, 2024 · CMS health inspection

    • Not serious Scope/severity B

      Type B Illinois Nursing Home Care Act violation

      Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b) and 300.3240a). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and 300.3240a).

      Statement of deficiencies (PDF)

18. Dec 19, 2023 Health · 3 findings
    • Not serious Scope/severity D Complaint

      F0577 Resident Rights Deficiencies

      Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

      Corrected Dec 27, 2023 · CMS health inspection

    • Serious Scope/severity G Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Dec 27, 2023 · CMS health inspection

    • Serious Scope/severity A

      Type A Illinois Nursing Home Care Act violation

      Type A: substantial probability of death or serious harm, or actual harm (1-129). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), and 300.1210d)6). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and 300.1210d)6).

      Statement of deficiencies (PDF)

19. Nov 15, 2023 Health · 2 findings
    • Not serious Scope/severity E Complaint

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Nov 22, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0725 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.

      Corrected Nov 22, 2023 · CMS health inspection

20. Oct 1, 2023 Health · 1 finding
    • Not serious Scope/severity E Complaint

      F0558 Resident Rights Deficiencies

      Reasonably accommodate the needs and preferences of each resident.

      Corrected Oct 4, 2023 · CMS health inspection

21. Sep 15, 2023 Fire Safety · 13 findings
    • Not serious Scope/severity F

      E0015 Emergency Preparedness Deficiencies

      Address subsistence needs for staff and patients.

      Corrected Oct 6, 2023 · CMS fire safety

    • Not serious Scope/severity D

      F0558 Resident Rights Deficiencies

      Reasonably accommodate the needs and preferences of each resident.

      Corrected Sep 25, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0676 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.

      Corrected Sep 25, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Sep 25, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Sep 25, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0694 Quality of Life and Care Deficiencies

      Provide for the safe, appropriate administration of IV fluids for a resident when needed.

      Corrected Sep 25, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0695 Quality of Life and Care Deficiencies

      Provide safe and appropriate respiratory care for a resident when needed.

      Corrected Sep 25, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0761 Pharmacy Service Deficiencies

      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.

      Corrected Sep 25, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Sep 25, 2023 · CMS health inspection

    • Not serious Scope/severity F

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected Oct 6, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0712 Miscellaneous Deficiencies

      Have simulated fire drills held at unexpected times.

      Corrected Oct 6, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Oct 6, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0929 Gas, Vacuum, and Electrical Systems Deficiencies

      Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

      Corrected Oct 6, 2023 · CMS fire safety

22. Aug 3, 2022 Fire Safety · 8 findings
    • Not serious Scope/severity E

      K0222 Egress Deficiencies

      Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

      Corrected Aug 25, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0321 Smoke Deficiencies

      Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

      Corrected Aug 25, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0351 Smoke Deficiencies

      Install an approved automatic sprinkler system.

      Corrected Sep 2, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0363 Smoke Deficiencies

      Install corridor and hallway doors that block smoke.

      Corrected Sep 7, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0372 Smoke Deficiencies

      Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

      Corrected Sep 1, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0511 Services Deficiencies

      Have properly installed electrical wiring and gas equipment.

      Corrected Sep 7, 2022 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Sep 1, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0923 Gas, Vacuum, and Electrical Systems Deficiencies

      Have proper medical gas storage and administration areas.

      Corrected Sep 7, 2022 · CMS fire safety

Owners and managers (as published by CMS)

• AHMED, WAHAJ — contracted managing employee, NOT APPLICABLE, since 02/01/2023
• WAHEED, MADIHA — w-2 managing employee, NOT APPLICABLE, since 02/01/2023
• ZEFFREN, EITAN — corporate officer, NOT APPLICABLE, since 02/01/2023
• BEN COHEN TRUST FBO JOANNA DAVISON — 5% or greater indirect ownership interest, 7%, since 02/01/2023
• BEN COHEN TRUST FBO JOHN C. DAVISON — 5% or greater indirect ownership interest, 7%, since 02/01/2023
• BEN COHEN TRUST FBO MARK EDWARD DAVISON — 5% or greater indirect ownership interest, 7%, since 02/01/2023
• ELK GROVE HOLDING COMPANY, LLC — 5% or greater direct ownership interest, 100%, since 02/01/2023