Inspection·October 27, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and develop fall preventive interventions to residents who are at risk for falls. This deficiency affects all four (R1, R2, R3 and R4) residents reviewed for Fall Prevention Management. Findings include: 1. R3 is admitted on [DATE], with diagnosis listed in part but not limited to Traumatic Subarachnoid Hemorrhage, fall encounter, Abnormalities of gait and mobility, Need assistance with personal care, Dementia, Psychosis. Fall admission assessment indicated at high risk for fall. Care plan indicates she is at high risk for fall due to poor safety awareness related to cognitive impairment, Gait/ imbalance problems, use if psychotropic medications. Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to call request for assistance. The resident has had an actual fall on 10/2/23 Laceration to the right temple with 3 staples, Subarachnoid Hemorrhage. R3 was re-admitted on [DATE]. On 10/25/23 at 9:42AM, R3 was laying on low bed pushed against the wall, with bed mattress on the floor on the right side of the bed. Her blanket was on the foot part of the bed. Call light is hanging by the wall away from her and not within reach. Breakfast tray at bedside untouched. R3 was sleeping. V22, LPN (Licensed Practical Nurse), was shown observation made. V22 said the call light should be within resident reach. V22 took the call light hanging from the wall and attached within resident reach. 2. R4 is re-admitted on [DATE] with diagnosis listed in part but not limited to Alzheimer's disease, anxiety disorder, history of falls. Quarterly fall assessment indicated at high risk for fall. R4 has several unwitnessed fall incidents in the facility. Care plan indicates she is at risk for falls due to unsteady balance and gait, poor safety awareness, attempts to get up unassisted, restless at times, potential, education side effects, Anxiety disorder, Pseudobulbar affect. Intervention: Bed in low position. On 10/25/23 at 9:48AM, R4 was laying on bed with floor mat on both sides of the bed. The bed was not in the lowest position. Her call light was hanging by the wall, away from her, and not within reach. V22, LPN, was shown observation made. V22 said that call light should be within resident reach. V22 took the call light hanging from the wall and attached within resident reach. V22 said the bed should be in the lowest position. V22 took the bed control and placed the bed to the lowest position. On 10/25/23 at 10:53AM, V22, LPN, said she made rounds earlier to both residents (R3 and R4), but (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 4 Event ID: 145350 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 145350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Rolling Meadows,the 4225 Kirchoff Road Rolling Meadows, IL 60008 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)