F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to provide Quality of Care/Treatment related to
clinical management of Urinary Tract Infection (UTI) affecting 1 of 4 (R3) residents reviewed for Quality of
Care/Treatment.
Residents Affected - Few
Findings Include:
On 3/11/2025 at 11:05 AM V3 (Assistant Director of Nursing/IP) stated on 1/13/2025, he received an order
from V18 (Nurse Practitioner) to start R3 with antibiotic Bactrim twice a day for 3 days. V3 stated he entered
the order into the electronic medication administration (EMAR) to reflect first dose in 1800 to be
administered by nurse on duty. Bactrim antibiotic was ordered STAT from Pharmacy and delivered on
1/14/2025 at 12:31AM to facility. V3 stated first dose of antibiotic can be obtained in the facility convenience
box (also known as pixes, capsca). V16 (Licensed Practical Nurse/LPN) nurse to give the first dose
acknowledged she did not give the Bactrim as ordered on 1/13 at 1800 to R3. V13 (Licensed Practical
Nurse), AM shift nurse on 1/14/25, verbally stated she gave the antibiotic Bactrim on 1/14/2025 at 0900 but
acknowledged not signing the EMAR. V13 said EMAR is signed as soon as medication is given, I should
have signed the EMAR.
On 3/13/2025 at 11AM, V2 (Director of Nursing) said medication should be given as ordered and nurse to
sign off on the EMAR for record administration.
Review of R3's Electronic Medication Administration (EMAR) dated 1/1/2025 - 1/31/2025 indicated no
nursing signature of administration on 1/13/2025 in 1800 and 1/14/2025 at 0900.
Review of Progress Note Effective date 1/11/2025 at 11:54 Type: Medical Practitioner Note (Physician/NP)
read: Late Entry: received a call from nurse that patient is complaining of pain with urination. Okay to collect
UA with culture reflex. Nurse to call with results. Review of V14 (Licensed Practical Nurse/LPN) 1/11/2025
Progress Note read: Received new order to collect UA, may straight cath if necessary. Review of Order
Summary Report, Order date 1/11/2025 read: Culture, Urine. No other order reviewed for UA (Urinalysis)
on 1/11/2025.
On 3/13/2025 at 11:28 AM, V18 said she was not aware that the order put in by the nurse on 1/11/25 was
only for culture and UA was not done.
On 3/11/2025 at 12:32 PM, V6 (Restorative Nurse) denied the allegation of R3 sustaining a fall due to
urinary tract infection (UTI). V6 stated R3's Fall incident on 12/18/24 investigated with root cause analysis of
R3 going to bathroom unassisted. On 12/22/24 R3 sustained another fall with root cause of transferring
without assist. V6 stated care plan was updated on both fall incident and R3 has not had any fall since the
last one in December.
(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
03/14/2025
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Reviewed R3's medical record: Fall Assessments (on Admission, Quarterly, Other) and Care Plan, no
concern.
Rounds to facility conducted. No resident complaint about Quality of Care/Treatment.
Reviewed Facility Policies and Procedure: Fall Prevention and Management, revised 4/8/2024, Medication
Administration, revision date 8/1/24, Antibiotic Stewardship, dated reviewed 8/20/22, Resident Change in
Condition Notification, date revised 12/18/23, no concern.
Event ID:
Facility ID:
145350
If continuation sheet
Page 2 of 2
