Pearl Of Montclare, The

Penalties

• Apr 2, 2026 — Fine ($29,520)
• Apr 2, 2026 — IDPH fine (Nursing Home Care Act) ($2,200)
• Apr 2, 2026 — IDPH fine (Nursing Home Care Act) ($2,200)
• Mar 14, 2025 — IDPH fine (Nursing Home Care Act) ($500)
• Mar 14, 2025 — IDPH fine (Nursing Home Care Act) ($500)
• Mar 14, 2025 — Fine ($14,505)
• Mar 14, 2025 — IDPH fine (Nursing Home Care Act) ($25,000)
• Aug 12, 2024 — IDPH fine (Nursing Home Care Act) ($25,000)
• Nov 17, 2023 — IDPH fine (Nursing Home Care Act) ($2,200)
• Nov 17, 2023 — Fine ($9,311)

Inspection findings

1. Jul 12, 2026 Health · 1 finding
   • Serious Scope/severity G Complaint Under dispute

     F0697 Quality of Life and Care Deficiencies

     Provide safe, appropriate pain management for a resident who requires such services.

     Corrected Jul 20, 2026 · CMS health inspection

2. May 23, 2026 Health · 1 finding
   • Not serious Scope/severity F Complaint

     F0804 Nutrition and Dietary Deficiencies

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

     Corrected May 29, 2026 · CMS health inspection

3. Apr 2, 2026 Health · 12 findings
   • 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 Apr 15, 2026 · CMS health inspection

   • Serious Scope/severity G

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

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

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0710 Nursing and Physician Services Deficiencies

     Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity E

     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 15, 2026 · 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 Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0805 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0813 Nutrition and Dietary Deficiencies

     Have a policy regarding use and storage of foods brought to residents by family and other visitors.

     Corrected Apr 15, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0908 Environmental Deficiencies

     Keep all essential equipment working safely.

     Corrected Apr 15, 2026 · 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), 300.1010h), 300.1210b), and 300.1210d)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)

   • 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)2)3)5). 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)5).

     Statement of deficiencies (PDF)

4. Mar 2, 2026 Health · 2 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 Mar 4, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 4, 2026 · CMS health inspection

5. May 29, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Jun 4, 2025 · CMS health inspection

6. Apr 18, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Apr 23, 2025 · CMS health inspection

7. Mar 14, 2025 Health · 18 findings
   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Apr 1, 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 Apr 1, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

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

     Corrected Apr 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Apr 1, 2025 · CMS health inspection

   • Serious Scope/severity G

     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 Apr 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Apr 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0700 Quality of Life and Care Deficiencies

     Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

     Corrected Apr 1, 2025 · 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 Apr 1, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Apr 1, 2025 · CMS health inspection

   • Not serious Scope/severity D

     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 Apr 1, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0805 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

     Corrected Apr 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0808 Nutrition and Dietary Deficiencies

     Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

     Corrected Apr 1, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 1, 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), and 300.1210d)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)

   • Not serious Scope/severity C

     Type C Illinois Nursing Home Care Act violation

     Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.1060e), 300.1060f), and 300.1060g). No Fine Total Fine: $26,000.00

     Statement of deficiencies (PDF)

   • Not serious Scope/severity C

     Type C Illinois Nursing Home Care Act violation

     Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.615e), 300.615f), and 300.615g). This instance in accordance with 300.282f) and j) of the Code is assessed a fine due to the violation of the sections of the Code with a high-risk designation: 300.615e), 300.615f), and 300.615g).

     Statement of deficiencies (PDF)

   • Not serious Scope/severity C

     Type C Illinois Nursing Home Care Act violation

     Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.625c)2). This instance in accordance with 300.282f) and j) of the Code is assessed a fine due to the violation of the sections of the Code with a high-risk designation: 300.625c).

     Statement of deficiencies (PDF)

8. Nov 14, 2024 Health · 1 finding
   • Not serious Scope/severity D 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 Nov 22, 2024 · CMS health inspection

9. Aug 12, 2024 Health · 3 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 Aug 28, 2024 · 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 Aug 28, 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), 300.1210c), 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)

10. Jun 3, 2024 Health · 1 finding
    • Not serious Scope/severity E Complaint

      F0684 Quality of Life and Care Deficiencies

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

      Corrected Jun 14, 2024 · CMS health inspection

11. Apr 19, 2024 Health · 1 finding
    • 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 May 1, 2024 · CMS health inspection

12. Apr 12, 2024 Fire Safety · 16 findings
    • Not serious Scope/severity F

      E0041 Emergency Preparedness Deficiencies

      Implement emergency and standby power systems.

      Corrected Apr 26, 2024 · CMS fire safety

    • Not serious Scope/severity E

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Apr 26, 2024 · CMS health inspection

    • Not serious Scope/severity E

      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 Apr 26, 2024 · 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 Apr 26, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Apr 26, 2024 · CMS health inspection

    • Not serious Scope/severity E

      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 Apr 26, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0692 Quality of Life and Care Deficiencies

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

      Corrected Apr 26, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0693 Quality of Life and Care Deficiencies

      Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

      Corrected Apr 26, 2024 · 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 Apr 26, 2024 · CMS health inspection

    • Not serious Scope/severity E

      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 Apr 26, 2024 · CMS health inspection

    • Not serious Scope/severity E

      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 Apr 26, 2024 · 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 Apr 26, 2024 · CMS health inspection

    • Not serious Scope/severity E 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 Apr 26, 2024 · CMS health inspection

    • Not serious Scope/severity F

      F0804 Nutrition and Dietary Deficiencies

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

      Corrected Apr 26, 2024 · CMS health inspection

    • Not serious Scope/severity F

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Apr 26, 2024 · CMS health inspection

    • Not serious Scope/severity F

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Apr 26, 2024 · CMS health inspection

13. Nov 17, 2023 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 Dec 7, 2023 · 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)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)

14. Sep 10, 2023 Health · 5 findings
    • Not serious Scope/severity F Complaint

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Oct 2, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0622 Resident Rights Deficiencies

      Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

      Corrected Oct 2, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0625 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.

      Corrected Oct 2, 2023 · CMS health inspection

    • 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 Oct 2, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Oct 2, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• CONLEY, ERIN — w-2 managing employee, NOT APPLICABLE, since 06/01/2023
• ZEFFREN, EITAN — corporate officer, NOT APPLICABLE, since 07/01/2023
• BEN COHEN TRUST FBO JOANNA DAVISON — 5% or greater indirect ownership interest, 9%, since 07/01/2023
• BEN COHEN TRUST FBO JOHN C. DAVISON — 5% or greater indirect ownership interest, 9%, since 07/01/2023
• BEN COHEN TRUST FBO MARK EDWARD DAVISON — 5% or greater indirect ownership interest, 9%, since 07/01/2023
• MONTCLARE HOLDING COMPANY LLC — 5% or greater direct ownership interest, 100%, since 07/01/2023