Pearl of Montclare, The

In the surveyor’s words

From the most serious findings on record at Pearl of Montclare, The, in the surveyor’s own words.

• Actual harm, isolatedF697Jul 12, 2026

  Based on observation, interview, and record review, the facility failed to a.) ensure medications were administered as ordered by the resident's physician and b.) provide pain management in accordance with the resident's comprehensive care plan and resident's goals for care and preferences. These failures affect two (R1, R2) out of four residents and caused R1 to experience severe pain while recovering from a spinal fracture in the facility.Findings include: R1's Face sheet documents that R1 was admitted to the facility on [DATE], with diagnoses not limited to wedge compression fracture of fifth lumbar vertebra, malignant neoplasm of unspecified site of unspecified female breast, and secondary malignant neoplasm of bone.R1's MDS/Minimum Data Set, dated [DATE], documents that R1 has a… […]

• Actual harm, isolatedF686Apr 2, 2026

  Based on observation, interview, and record review the facility failed to ensure the low air loss mattresses were used in accordance with facility policy to promote effective pressure redistribution (inappropriate layering of multiple linens) for two residents (R2 and R4); and failed to ensure a resident (R5) with a acquired stage 4 pressure ulcer received wound care as ordered by the physician resulting in the development of a wound infection, requiring IV (intravenous) antibiotic therapy. These failures affected 3 of 3 residents (R2, R4 and R5) reviewed for pressure ulcers in the sample of 61. […]

• Actual harm, isolatedF689Mar 14, 2025

  Based on interviews and records reviews, the facility failed to follow a resident's (R95) fall care plan intervention and physician recommendation with multiple history of falls to ensure soft head helmet was applied while in bed for 1 (R95) out of 1 resident reviewed for falls. This failure resulted in R95 sustaining a left subdural hematoma after falling and hitting head on the floor on 2/4/25. Findings Include: R95's clinical records show an initial admitted [DATE] with included diagnoses but not limited to anxiety disorder, traumatic subdural hemorrhage, other lack of coordination, other abnormalities of gait and mobility, and epilepsy. […]

• Actual harm, isolatedF689Aug 12, 2024

  Based on interview and record review, the facility failed to utilize a gait belt during resident transfer, from toilet to wheelchair, for one of three residents (R1) reviewed for falls. This failure resulted in R1 falling and sustaining a left femur fracture. Findings include: Facility's incident report (Final of 7.13.2024) R1 is a [AGE] year-old on 8/13/2021. Diagnoses include Acute Systolic Congestive Heart Failure, Overactive Bladder, Hypertension, Anemia, Anxiety Disorder, Hyperlipidemia, Alzheimer Disease, Dementia Without Psychotic Disturbance, Legally Blind, and Polyarthritis. Patient is alert and oriented x3. Patient is legally blind and requires supervision with toileting/hygiene care, transfers, bed mobility, and ambulation with a rollator walker. […]

• Actual harm, isolatedF689Nov 17, 2023

  Based on interviews and records review, the facility failed to ensure resident safety for one resident (R2) of three residents reviewed. This failure resulted in R2 falling and sustained right leg laceration. R2 was taken to the emergency room and received sutures on the right leg. R2 is not currently in the facility. Findings include: According to current POS (Physician Order Sheet), R2 is an [AGE] year-old individual admitted to the facility on [DATE]. R2's medical diagnosis includes but not limited to: Acute on chronic diastolic (congestive) heart failure, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. […]