Pearl of Rolling Meadows: Transfer Notice Failure - IL
Federal inspectors cited The Pearl of Rolling Meadows on August 13, 2025, after a complaint investigation found that staff failed to notify the receiving emergency room before transferring the resident, identified in records only as R1, following an unwitnessed fall on August 12.
R1 was found on the bedroom floor with a pillow under his head. He was alert but oriented only to himself, meaning he could not say what had happened or provide his own medical history. A nurse practitioner ordered him sent to a local emergency room for evaluation. The ambulance was called. And then, by the account of the nurses themselves, nobody called the hospital.
The first nurse, identified in the report as V4, told inspectors she prepared the transfer documents while R1 waited for the ambulance. She said she did not notify the emergency room because she did not know when the ambulance would arrive. She gave report to the oncoming nurse and considered her part done.
The second nurse, V6, took over when the ambulance arrived. He handed the paramedics the paperwork. He did not call the hospital either. His explanation was direct: "That is for the ambulance driver to do — we don't do that here."
R1's admission record, dated August 12, 2025, listed a diagnosis of delirium due to a known physiological condition, along with cognitive abnormalities and impaired gait and mobility. A care plan entered the same day documented dementia and impaired thought processes. He was not a patient who could walk into an emergency room, introduce himself, and explain that he had fallen in a nursing home and couldn't remember anything before that. The ER would have been receiving him cold.
The facility's own transfer policy, revised as recently as February 28, 2025, spells out that when an emergency transfer to a hospital becomes necessary, the facility will notify the receiving facility that the transfer is being made. The policy existed. Both nurses knew a transfer was happening. Neither followed it.
The Director of Nursing, V2, did not hedge when inspectors asked. "I expect all nurses to notify the receiving facility of a transfer even if they can advocate for themselves or not," she said. "R1 is confused and cannot speak for himself — the local emergency room hospital should have been notified." The administrator, V1, said the same: every nurse is expected to give a full report to the receiving facility for any resident being transferred.
So two nurses, a director of nursing, an administrator, and a written policy all pointed to the same conclusion. The only people who didn't follow through were the two nurses who were actually in the room.
The violation was rated at the lowest level of harm, meaning inspectors found minimal harm or potential for actual harm rather than documented injury resulting from the lapse. That rating reflects what inspectors could confirm, not necessarily what the emergency room team faced when an elderly, confused man arrived without a phone call, without context, and without anyone having told them he was coming.
V6's explanation, the one about it being the ambulance driver's job, is the detail that stays. It suggests not a momentary lapse but a settled belief about where responsibility ends. The facility's policy says one thing. The nurse had decided, at some point before August 12, that the policy described someone else's job.
R1 arrived at the emergency room. What the staff there knew about him when he came through the door, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pearl of Rolling Meadows,the from 2025-08-13 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
PEARL OF ROLLING MEADOWS,THE in ROLLING MEADOWS, IL was cited for violations during a health inspection on August 13, 2025.
R1 was found on the bedroom floor with a pillow under his head.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.