Pearl of Montclare: Medication Error Rate Violation - IL
The citation, recorded during a March 14 inspection at the facility on North Nordica Avenue in Chicago's Montclare neighborhood, placed the violation at a level inspectors described as causing minimal harm or the potential for actual harm. A few residents were affected.
That phrase, "potential for actual harm," carries weight in nursing home oversight. Medication errors at this threshold are not paperwork problems. They represent a pattern, not a single mistake. When inspectors calculate an error rate, they observe nurses and aides administering medications across a sample of residents and count how many doses are given incorrectly, skipped, given at the wrong time, or administered to the wrong person. A rate at or above five percent means that out of every twenty medication administrations observed, at least one went wrong.
Pearl of Montclare is a licensed nursing facility operating under CMS provider number 145844. The March inspection was a standard health survey.
The medication administration finding was tagged under F0759, one of the federal deficiency codes that specifically targets error rates rather than isolated incidents. The distinction matters. A single nurse making a single mistake on a single shift is a different problem than a facility-wide pattern that survives across multiple observations and multiple staff members. F0759 citations are reserved for the latter.
Inspectors noted that few residents were affected, which placed the scope of the violation at the lower end of the scale. But scope and severity are separate measures. A violation affecting few residents can still represent a systemic breakdown in how a facility handles the medications that many of its residents depend on to manage pain, infection, blood pressure, blood sugar, seizures, and psychiatric conditions.
The inspection report does not identify which residents received incorrect medications, what drugs were involved, or what specific errors inspectors observed during administration. The narrative provided to regulators points to the F700 citation for details, and the underlying detail in the public record is limited to what appears above.
What the record does show is that Pearl of Montclare's medication administration practices failed to meet a standard that has been part of federal nursing home oversight for decades, and that the failure was significant enough to document and cite during a routine inspection in the first quarter of 2025.
Medication errors in nursing homes carry particular risk because the residents receiving those medications are often unable to recognize that something has gone wrong. A resident with advanced dementia cannot tell a family member that she received twice her normal dose of a blood thinner, or that her insulin was skipped for the second morning in a row. A resident who is non-verbal after a stroke cannot report that the nurse gave him a pill that looked different from the one he usually takes. The population that nursing homes serve is, by definition, the population least equipped to catch the mistakes made on their behalf.
Family members who have a loved one at Pearl of Montclare and want to understand what the inspection found in more detail can request the full statement of deficiencies from the facility directly or from the Illinois Department of Public Health, which conducts nursing home surveys in the state on behalf of CMS. The full inspection report, including any plan of correction the facility submitted in response, is also available through Medicare's Care Compare database.
The inspection was completed March 14, 2025. Whether the error rate has been corrected since then, and what specific changes the facility made to its medication administration process, is not reflected in the public record reviewed for this report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pearl of Montclare, The from 2025-03-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
PEARL OF MONTCLARE, THE in CHICAGO, IL was cited for violations during a health inspection on March 14, 2025.
That phrase, "potential for actual harm," carries weight in nursing home oversight.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.