Pearl of Rolling Meadows,The

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 27, 2025

  Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision for residents at high risk for falls and failed to implementing interventions for a resident with wandering behaviors. These failure applied to three of five residents (R52, R56, and R61) reviewed for falls and resulted in R52 sustaining a right hip fracture and a head injury requiring medical treatment. Findings include: Per the facility's incident log from 09/01/2024 - 03/24/2025 the facility has had 73 unwitnessed falls with 18 of them involving memory care residents, R52 had a fall each month from December 2024 - March 2025 with two of them being unwitnessed, and R61 had four falls within three weeks of admission with three of them being unwitnessed. 1. […]

• Actual harm, isolatedF689Aug 1, 2024

  Based on interview and record review, the facility failed to properly monitor/supervise a high fall risk resident and ensure safety during incontinence care. This affected one of three (R2) residents reviewed for safety during care. This failure resulted in R2 rolling out of bed suffering a laceration to the head which required six sutures at the hospital. Findings Include: R2 is a [AGE] year old with the following diagnosis: malignant neoplasm of the stomach, dementia, anxiety disorder, and repeated falls. An Incident note dated 6/5/24 documents the CNA (V10 - Former CNA) called the nurse's attention to R2's room. R2 was observed lying on R2's left side on the floor with a red substance noted on the floor. R2 stated that R2 rolled out of bed. […]

• Actual harm, isolatedF689May 12, 2023

  Based on observation, interview, and record review, the facility failed to implement fall interventions for 2 of 3 residents (R4 and R5) reviewed for fall interventions and supervision in a sample of 14 residents. This failure resulted in R4 falling out of bed and sustaining a nasal fracture. Findings include: The Face Sheet documents R4 was admitted to the facility on [DATE], with a diagnosis of cognitive communication deficit and unsteadiness of gait and mobility. The care plan on admission documents R4 was at high risk for falls. […]

• Actual harm, isolatedF684Feb 13, 2022

  Based on observation, interview, and record review, the facility failed to follow physician order and facility policy regarding a stat order for X-ray. The facility also failed to notify the attending physician of the results of the X-ray once obtained until the next day. This failure resulted in a delay of treatment and pain for R1 for over 40 hours. This applies to 1 of 3 residents (R1) reviewed for injuries of unknown origin. The findings include: The EHR (Electronic Health Record) shows R1 was originally admitted to the facility on [DATE]. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress notes, dated 1/18/2022 at 2:45 P.M., shows R1 was guarding R1's left hip due to pain when therapy treatment was being provided. […]

• Actual harm, isolatedF689Jan 11, 2021

  Based on observations, interviews, and record review, the facility failed to implement the fall prevention policy, failed to update and modify a resident's plan of care, and failed to provide supervision for high risk fall residents. This failure resulted in R3 falling and sustaining an occipital bone fracture. This applies to 1 of 3 residents (R3) reviewed for fall from a sample of 11. Findings include: Record review of an incident report, dated 4/16/20, documented R3 had a fall in the dining room on 4/16/20. Record review on fall care plan indicates that the facility didn't update the fall care plan to prevent further falls through incorporating the root cause of the fall. […]