Inspection·February 11, 2025

F 0777 Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure diagnostic testing results were reported and reviewed in a timely manner for 1 of 1 residents reviewed for medical testing in the sample of 5. Residents Affected - Few The findings include: R1's admission record documents he was admitted to the facility on [DATE] with a primary diagnosis of acute respiratory failure with hypoxia (low levels of oxygen). The 1/17/25 resident care and screening assessment documents R1 to have moderate cognitive impairment. On 1/13/25, V12 (Nurse Practitioner-NP) ordered R1 to have a repeat chest x-ray with a diagnosis of history of bilateral pleural effusions (fluid in the lung tissues). The order was noted by nursing two days later 1/15/25. The x-ray results of the 1/15/25 chest x-ray show right basilar opacity. Correlate clinically for atelectasis (collapse of a lung or section of a lung), chronic scarring, edema, and/or pneumonia. The 1/15/25 x-ray report shows it was reported on 1/15/25 at 9:24 AM, however, the report with orders shows on 1/21/25, V12 ordered an antibiotic due to a diagnosis of pneumonia. On 2/11/25 at 9:53 AM, V3 (R1's daughter) said when R1 was admitted he had been complaining of a cough and sore throat. She said the symptoms were reported to nursing, and nothing seemed to get done. The nurses were checking R1's lungs, and reporting they were clear. She said eventually a nurse ordered breathing treatments and some cold medication. It was not until she attended the care team meeting with the staff, she learned R1 had a chest x-ray on 1/15/25 that showed pneumonia, but she was not advised of an antibiotic starting until 1/21/25. She said R1 went 6 days without getting any medication. On 2/11/25 at 10:45 AM, V5 LPN (Licensed Practical Nurse) said when an x-ray is ordered, the order is placed in the computer, and it will go to the x-ray company, and they will do the exam and fax the results to the facility. She said the nurse is responsible to getting results and reporting them to the provider. She said if a resident had a result of pneumonia, she would just fax it to the NP. On 2/11/25 at 11:14 AM, V7 RN (Registered Nurse) said when an x-ray is ordered, the order is placed in the computer, and the nurse must call to schedule a time for the exam. When the exam is complete, results are reported right away. Those results are faxed to the NP, and we await orders. On 2/11/25, V2 DON (Director of Nursing) said all x-ray orders are called in and scheduled. Results are faxed typically within a couple of hours. It can be hit or miss as to what number the results are sent; we have educated the staff to forward results to the correct nursing station. When the faxed results are in, they are forwarded to the medical group for review, and they will give direction. They send back the same test results with orders pasted to the bottom of the page. V2 said the original x-ray order should have been processed and completed on 1/13/25 when it was written. V2 said if the x-ray and results were done and reviewed on 1/15/25, R1 could have started the antibiotic earlier. The facility's 10/2024 policy for physician notification of laboratory/radiology/diagnostic results documents its purpose is to assure physician ordered diagnostic test are performed, and to assure test results are reported to the physician so that prompt, appropriate action may be taken if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 2 of 3 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 145058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Chillicothe 1028 Hillcrest Drive Chillicothe, IL 61523 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 0777 indicated for the resident's care. A nurse is responsible for monitoring the receipt of test results. Test results should be reported to the physician or other practitioner who ordered them. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145058 If continuation sheet Page 3 of 3