The Vardell Report.Pearl of Montclare, the

Across 13 inspections from November 2023 to July 2026, state surveyors documented 50 findings at Pearl of Montclare, the; 50 have a recorded correction; CMS lists 4 enforcement actions in the window.

Inspections

13

2023–2026, complaint and standard

Findings

50

Deficiencies cited by state inspectors

Corrected

50

Of 50 findings, with a recorded correction date

Penalties

4

4 fines; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Jul 122026

   Complaint investigation

   1 finding

   • F697Provide safe, appropriate pain management for a resident who requires such services.Level GActual harmCorrected Jul 20, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. May 232026

   Complaint investigation

   1 finding

   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level FNo actual harm, potential for moreCorrected May 29, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Apr 22026

   Standard health inspection

   10 findings

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Apr 15, 2026
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Apr 15, 2026
   • F908Keep all essential equipment working safely.Level FNo actual harm, potential for moreCorrected Apr 15, 2026
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Apr 15, 2026
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Apr 15, 2026
   • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level ENo actual harm, potential for moreCorrected Apr 15, 2026
   • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreCorrected Apr 15, 2026
   • F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Apr 15, 2026
   • F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Level DNo actual harm, potential for moreCorrected Apr 15, 2026
   • F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Level DNo actual harm, potential for moreCorrected Apr 15, 2026

   Enforcement Action

   Civil money penalty, $29,520 imposed April 2, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 2, 2026, the nearest before the penalty date.

   Enforcement Action

   Civil money penalty, $15,750 imposed July 12, 2026. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 2, 2026, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Mar 22026

   Complaint investigation

   2 findings

   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Mar 4, 2026
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Mar 4, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. May 292025

   Complaint investigation

   1 finding

   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jun 4, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Apr 182025

   Complaint investigation

   1 finding

   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 23, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Mar 142025

   Standard health inspection

   14 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Apr 1, 2025
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Apr 1, 2025
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level ENo actual harm, potential for moreCorrected Apr 1, 2025
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Apr 1, 2025
   • F700Try 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.Level ENo actual harm, potential for moreCorrected Apr 1, 2025
   • F808Ensure 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.Level ENo actual harm, potential for moreCorrected Apr 1, 2025
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Apr 1, 2025
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F758Implement 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.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F803Ensure 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.Level DNo actual harm, potential for moreCorrected Apr 1, 2025
   • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level DNo actual harm, potential for moreCorrected Apr 1, 2025

   Enforcement Action

   Civil money penalty, $14,505 imposed March 14, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 14, 2025, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Nov 142024

   Complaint investigation

   1 finding

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Nov 22, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Aug 122024

   Complaint investigation

   1 finding

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Aug 28, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

10. Jun 32024

    Complaint investigation

    1 finding

    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Jun 14, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

11. Apr 192024

    Complaint investigation

    1 finding

    • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected May 1, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

12. Apr 122024

    Standard health inspection

    15 findings

    The same visit included a complaint investigation.

    • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level FNo actual harm, potential for moreCorrected Apr 26, 2024
    • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Apr 26, 2024
    • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Apr 26, 2024
    • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Apr 26, 2024
    • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level ENo actual harm, potential for moreCorrected Apr 26, 2024
    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Apr 26, 2024
    • F692Provide enough food/fluids to maintain a resident's health.Level ENo actual harm, potential for moreCorrected Apr 26, 2024
    • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Apr 26, 2024
    • F758Implement 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.Level ENo actual harm, potential for moreCorrected Apr 26, 2024
    • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Apr 26, 2024
    • F803Ensure 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.Level ENo actual harm, potential for moreCorrected Apr 26, 2024
    • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Apr 26, 2024
    • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Apr 26, 2024
    • F693Ensure 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.Level DNo actual harm, potential for moreCorrected Apr 26, 2024
    • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Apr 26, 2024

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

13. Nov 172023

    Complaint investigation

    1 finding

    • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Dec 7, 2023

    Enforcement Action

    Civil money penalty, $9,311 imposed November 17, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the complaint investigation of November 17, 2023, the nearest before the penalty date.

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Accident Hazards and Supervision, Cited in Five Inspections

   Inspectors cited F689 in November 2023, April 2024, August 2024, November 2024 and March 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242425252526262626F689 across all 13 inspections, oldest to newest
2. 2

   Pressure Injury Care, Cited in Four Inspections

   Inspectors cited F686 in April 2024, March 2025, March 2026 and April 2026. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242425252526262626F686 across all 13 inspections, oldest to newest
3. 3

   Kitchen and Food Safety, Cited in Three Inspections

   Inspectors cited F812 in April 2024, March 2025 and April 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242425252526262626F812 across all 13 inspections, oldest to newest
4. 4

   Citation F676, Cited in Two Inspections

   Inspectors cited F676 in April 2024 and April 2026. The agency describes it this way: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242425252526262626F676 across all 13 inspections, oldest to newest
5. 5

   Help With Daily Living, Cited in Two Inspections

   Inspectors cited F677 in April 2024 and March 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242425252526262626F677 across all 13 inspections, oldest to newest
6. 6

   Quality of Care, Cited in Two Inspections

   Inspectors cited F684 in April 2024 and June 2024. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242425252526262626F684 across all 13 inspections, oldest to newest
7. 7

   Nutrition and Hydration, Cited in Two Inspections

   Inspectors cited F692 in April 2024 and April 2026. This citation covers whether residents get enough food and fluids to stay healthy. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242425252526262626F692 across all 13 inspections, oldest to newest
8. 8

   Respiratory Care, Cited in Two Inspections

   Inspectors cited F695 in April 2024 and March 2025. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242425252526262626F695 across all 13 inspections, oldest to newest
9. 9

   Psychotropic Medications, Cited in Two Inspections

   Inspectors cited F758 in April 2024 and March 2025. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   23242424242425252526262626F758 across all 13 inspections, oldest to newest
10. 10

    Medication Error Rate, Cited in Two Inspections

    Inspectors cited F759 in March 2025 and May 2025. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242425252526262626F759 across all 13 inspections, oldest to newest
11. 11

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in April 2024 and April 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242425252526262626F761 across all 13 inspections, oldest to newest
12. 12

    Citation F803, Cited in Two Inspections

    Inspectors cited F803 in April 2024 and March 2025. The agency describes it this way: 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. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242425252526262626F803 across all 13 inspections, oldest to newest
13. 13

    Food Quality and Temperature, Cited in Two Inspections

    Inspectors cited F804 in April 2024 and May 2026. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242425252526262626F804 across all 13 inspections, oldest to newest
14. 14

    Citation F805, Cited in Two Inspections

    Inspectors cited F805 in March 2025 and April 2026. The agency describes it this way: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242425252526262626F805 across all 13 inspections, oldest to newest
15. 15

    Infection Control, Cited in Two Inspections

    Inspectors cited F880 in April 2024 and March 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    23242424242425252526262626F880 across all 13 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in five inspections, most seriously at level G.

2. 02

   How often are residents checked for pressure injuries and repositioned, and who is responsible for it?

   Pressure Injury Care: cited in four inspections, most seriously at level G.

3. 03

   May we see the kitchen, and what do your own sanitation checks look like week to week?

   Kitchen and Food Safety: cited in three inspections, most seriously at level F.

4. 04

   What changed after F676 was cited, and how do you check it now?

   Citation F676: cited in two inspections, most seriously at level E.

5. 05

   How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

   Help With Daily Living: cited in two inspections, most seriously at level D.

6. 06

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in two inspections, most seriously at level E.

7. 07

   How are weight and fluid intake tracked, and what happens when a resident starts losing weight?

   Nutrition and Hydration: cited in two inspections, most seriously at level E.

8. 08

   Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

   Respiratory Care: cited in two inspections, most seriously at level E.

9. 09

   How many residents take psychotropic medications, and how often are doses reviewed for reduction?

   Psychotropic Medications: cited in two inspections, most seriously at level E.

10. 10

    How are medication passes checked, and what happens when an error is found?

    Medication Error Rate: cited in two inspections, most seriously at level D.

11. 11

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in two inspections, most seriously at level E.

12. 12

    What changed after F803 was cited, and how do you check it now?

    Citation F803: cited in two inspections, most seriously at level E.

13. 13

    May we try a meal, and how do you check food temperature by the time it reaches residents?

    Food Quality and Temperature: cited in two inspections, most seriously at level F.

14. 14

    What changed after F805 was cited, and how do you check it now?

    Citation F805: cited in two inspections, most seriously at level E.

15. 15

    Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

    Infection Control: cited in two inspections, most seriously at level F.

16. 16

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    Insufficient nursing staff was cited in April 2024.

17. 17

    What led to the 2026 fine, and has it been paid?

    A $15,750 civil money penalty was imposed July 12, 2026. CMS publishes the fine, not whether it has been paid. The record holds four enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Illinois state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Nov 17, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Apr 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Apr 19, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Jun 3, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Aug 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Nov 14, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Mar 14, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Apr 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection May 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Mar 2, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Apr 2, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection May 23, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Illinois state survey agency

  Inspection Jul 12, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 145844

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.