Inspection·June 12, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure call light cords were within reach for 4 residents (R6, R7, R8, and R9) out of 9 residents reviewed for call light accessibility. Residents Affected - Some Findings include: 1. R7's call light ability screen, dated 5/22/24, notes R7 is able to use the call light. On 6/10/24 at 11:00 AM, R7 was observed lying in bed. There was no call light cord observed near R7's bed. On 6/10/24 at 11:05 AM, V3, RN (Registered Nurse) was unable to locate R7's call light cord. After searching R7's room, V3 found R7's call light cord under the blanket of R7's roommate's bed. V3 stated R7's call light cord should be within reach of R7. 2. R8's call light ability screen, dated 5/16/24, notes R8 is able to use the call light. On 6/10/24 at 11:10 AM, R8 was observed lying in bed. R8's call light cord was observed between R8's mattress and bed frame. R8's call light cord was not within reach. 3. R9's call light ability screen, dated 5/15/24, notes R9 is able to use the call light. On 6/10/24 at 11:13 AM, R9 was observed lying in bed. R9's call light cord was observed tangled in R9's bed frame. R9's call light cord was not within reach. 4. R6's call light ability screen, dated 5/17/24, notes R6 is able to use the call light. On 6/10/24 at 11:15 AM, R6 was observed lying in bed with call light cord wrapped around lamp on nightstand and dangling behind the nightstand. Call light cord was not within reach of R6. On 6/10/24 at 10:30 AM, V4 (nurse) stated the resident's call light cord should be within easy reach at all times. On 6/11/24 at 2:30 PM, V1 (Administrator) stated when the residents are in their rooms, staff should clip the call light cord to the resident's shirt so it can easily be reached by resident. The facility's call light use policy, dated 6/19/2020, notes a call light ability screen will be completed for each resident to determine the ability to use the call light. Residents capable of using (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: 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 06/12/2024 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)