Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 staff failed to immediately notify the nurse when a resident
had a change in condition and could no longer stand and/or bear weight on her leg after a transfer. This
resulted in a delay in care and treatment for R1 who had a hip dislocation. This applies to 1 of 3 residents
(R1) reviewed for change in condition in the sample of 3.
Residents Affected - Few
The findings include:
The Incident Report for R1 dated 2/1/25 showed, R1 complained of pain in her left leg and stated her left
leg got twisted when she was being transferred after her shower. The nurse assessed R1's left leg and
noted it was swollen and had poor alignment. R1 was sent to the hospital.
On 2/25/25 at 11:07 AM, R1 was sitting in a wheelchair in the dining room for an activity. R1 had an
abductor pillow between her legs that was not properly placed. The abductor pillow did not line up on each
side with her legs. The abductor pillow was crooked and the straps were not securely in place. R1 stated
she had the pillow because she had hip surgery. R1 was questioned regarding an incident in the shower
that occurred on 2/1/25. R1 stated she was in the shower, standing, and there was one CNA (Certified
Nursing Assistant) with her. R1 stated her leg slid and twisted. R1 stated she could not stand up after her
shower and she had a lot of hip pain.
On 2/25/25 at 11:24 AM, V4 RN (Registered Nurse) stated, she told V5 CNA to give R1 a shower because
V3 (R1's brother/POA - power of attorney) requested it. V4 stated the shower was between 2:30 PM - 3:30
PM. V4 stated it was the end of her shift so she left. V4 stated R1 said her leg was twisted or something
during the transfer in the shower room.
On 2/25/25 at 11:47 AM, V5 CNA stated she took R1 into the shower room and had R1 stand up at the
grab bar in the shower room. V5 was asked if she applied a transfer belt around R1. V5 stated she had a
transfer belt on R1. V5 stated she transferred R1 from her wheelchair to a shower chair alone. V5 stated
she told R1 to grab the bar on the wall in the shower room. V5 stated she did R1's shower and put her
clothes on her. V5 stated she asked R1 to stand and R1 stated she couldn't stand so she didn't try to stand
her. V5 stated she called V7 CNA to help her transfer R1. V5 stated V7 helped transfer R1 to her
wheelchair. V5 stated R1 was taken to her room and sat in her wheelchair for a few minutes and then was
transferred to bed. V5 stated she never told the nurse that R1 couldn't stand after her shower because V4
RN had already left. V5 stated she did not tell V8 RN, the oncoming nurse, that R1 could not stand after her
shower. V5 stated she didn't tell the nurse that R1 couldn't stand because sometimes residents just say that
because they don't want to stand. V5 stated she told V8 RN that R1 had pain.
On 2/25/25 at 3:17 PM, V8 RN stated, she worked 2/1/25 on the 3:00 PM - 11:00 PM shift. V8 stated
(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:
145111
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
145111
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/26/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Elmhurst Extended Care Center
200 East Lake Street
Elmhurst, IL 60126
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
she did not know R1 had a shower and the CNA did not notify her that R1 had a change in condition. V8
stated she was passing medication between 4:00 PM - 6:00 PM and heard R1 shouting. V8 stated R1 does
that to get attention so she did not check on her and asked the CNA to go and see what R1 needed. The
CNA stated R1 had pain so she went in and R1 said her leg was hurting. R1 told her she took a shower
and when she was transferred her leg flipped or twisted and she was in pain. V3 (R1's brother) was sitting
in the room and he said R1's foot did not look properly aligned. V8 stated she looked at R1's foot and it was
turned in. She also noted swelling and a sore to her heel. V8 looked at her phone and the messages to the
physician. V8 stated she contacted the doctor at 5:58 PM and at 6:09 PM she received an order from the
doctor to get an X-ray. The X-ray couldn't be done right away. V8 stated she medicated R1 for pain. At 8:47
PM she notified the doctor the x-ray could not be done until the next day. V8 stated she received an order to
send R1 to the hospital. V8 stated R1 went to the hospital at 9:15 PM.
On 2/25/25 at 1:50 PM, V1 (Administrator) stated the CNA should have reported R1's change in condition
to the nurse so she could take further intervention and contact the medical doctor.
On 2/25/25 at 2:17 PM, V13 NP (Nurse Practitioner) stated when R1 had a change in condition with her
shower the first thing the CNA should have done was contact the nurse so the nurse could assess the
resident. V13 stated she would expect the nurse to be notified right away and did not know why anyone
would wait to notify the nurse. V13 stated notifying the nurse is important so the nurse can find out why
there is a change and then contact them (physician/NP). V13 stated waiting longer than an hour to send a
resident out is too long. V13 stated it was important to send the resident out right away to make sure
nothing else going on and so the situation did not become worse.
On 2/25/25 at 2:25 PM, V2 DON (Director of Nursing) stated, the CNA should have called for the nurse and
informed her of what's going on. V2 stated that have been done right away. V2 stated there was a delay in
care. V2 it was a big span of time and a lot could happen during that time.
The Face Sheet dated 2/25/25 for R1 showed diagnoses including left femur fracture, joint replacement
surgery, dislocation of left hip prosthesis, osteoporosis without current pathological fracture, osteoarthritis,
abnormalities of gait and mobility, hypertension, hyperlipidemia, morbid obesity, bipolar disorder,
schizphrenia, and major depressive disorder.
The Facility's Ethic's - Patient's Change of Condition policy (1/10/25) showed, if patient's condition should
change suddenly, it is the obligation of the charge nurse to notify the attending physician and responsible
family member of the patient's condition change. The policy does not show any time frames for staff
notification to the nurse or the nurse's time frame for notification to a provider.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145111
If continuation sheet
Page 2 of 2
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the February 26, 2025 survey of ELMHURST EXTENDED CARE CENTER?
This was a inspection survey of ELMHURST EXTENDED CARE CENTER on February 26, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ELMHURST EXTENDED CARE CENTER on February 26, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.