F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, interviews, and record reviews, the facility failed to ensure a medication
administration error rate of <5% for 2 (R2 and R5) residents of 4 (R2, R4, R5, and R6) residents reviewed
for medication administration. There were 33 opportunities with 3 errors resulting in 9.09% medication
administration error rate.
Residents Affected - Few
Findings include:
On 05/27/2025 at 11:15am, V5 (Licensed Practice Nurse) dispensed R2's medications including:
Senna 8.6 mg/tab x 2 tablets - this is an error. R2's (Active Order as Of: 05/27/2025) Order Summary
Report documented, in part Senna S Oral tablet 8.6-50mg (Sennosides-Docusate sodium) give 2 tablets by
mouth two times a day.
Folic Acid 800mcg x 1 tab - this is an error. R2's (Active Order as Of: 05/27/2025) Order Summary Report
documented, in part Folic Acid Oral tablet 1 MG (1000mcg) 1 tablet by mouth one time a day.
On 05/27/2025 at 2:52pm with V2 (Director Of Nursing), this surveyor requested V5 to show V2 the Over
the Counter containers of Senna and Folic Acid that were administered to R2. V5 showed the containers to
the surveyor and to V2. Inquiring if the orders and what were administered to R2 were the same, V2 stated
these are not the same medications. V5 stated I have been giving him these medications.
R2's (Active Order as Of: 05/27/2025) Order Summary Report documented, in part Diagnoses: (include but
not limited to) swelling, mass and lump lower limb bilateral, non-pressure chronic ulcer of part of left and
right lower leg.
R2's (05/07/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS
(Brief Interview for Mental Status) Summary Score: 09. Indicating R2's mental status as moderately
impaired.
On 05/28/2025 at 9:25am, V11 (Registered Nurse) dispensed R5 medications including:
Calcium Carbonate 500mg x 1 tab (brand name: Alkums) - this is an error. R5's (Active Order as Of:
05/28/2025) Order Summary Report documented, in part Calcium Carbonate-Vitamin D tablet 500-200Mg,
give 1 tablet by mouth in the morning.
R5's (Active Order as Of: 05/28/2025) Order Summary Report documented, in part Diagnoses: (include but
not limited to) hypokalemia, hyponatremia, and hypertension.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145844
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145844
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pearl of Montclare, The
2833 North Nordica Avenue
Chicago, IL 60634
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Level of Harm - Minimal harm
or potential for actual harm
R5's (04/29/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS
(Brief Interview for Mental Status) Summary Score: 13. Indicating R5's mental status as cognitively intact.
The (undated) Facility provided 'Alkums Antacid' documented, in part Active ingredient (in each tablet)
Calcium Carbonate 500mg. Of note, vitamin D is not listed as an active ingredient.
Residents Affected - Few
The (undated) Nurse supervisor RN/LPN Job description documented, in part JOB summary: Within scope
of practice, coordinates care delivery, which will ensure that patient's needs are met in accordance with
professional standards of practice through physician orders, center policies and procedures, and federal,
state, and local guidelines. General Nursing Care Responsibilities. Demonstrates the ability to administer
medications according to facility policy. Demonstrate ability to carry out physician orders.
The (05/02/2025) Administering Medications documented, in part Policy Statement: The Facility will ensure
that medications are administered in a safe and timely manner, and as prescribed. Procedure: 3.
Medications are administered in accordance with prescriber orders. 8. The individual administering the
medication checks the label THREE (3) times to verify the right medication and right dosage.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145844
If continuation sheet
Page 2 of 2
