Inspection·October 30, 2023

F 0610 Respond appropriately to all alleged violations. 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 an injury of unknown origin was investigated for 1 of 4 residents (R2) reviewed for injuries in the sample of 11. Residents Affected - Few The findings include: On 10/30/23 at 2:40 PM, V9 (R2's caregiver) said R2 had a bruise about the size of a quarter to the middle of R2's forehead which wasn't there the previous day. V9 said she has a picture of the bruise, and she reported it to the nurse. V9 stated she doesn't remember nurse's name, but she was not a regular nurse, she was agency on 9/10/23. V9 said the wound was definitely a bruise, not a scratch, and it took weeks to heal. V9 said the nurse told her she was going to make a report. V9 said R2 was nonverbal and couldn't tell what happened. On 10/30/23 at 12:37 PM, V4 (Registered Nurse/RN) said R2's caregiver told her there was a bruise to R2's head. V4 said the nurses who work in the facility all the time said the bruise had been there on the evening shift the day prior, but there wasn't anything documented in progress notes. V4 said she did not fill out an incident report. V4 said she sent a message about R2's forehead wound to the wound care team. On 10/20/23 at 11:22 AM V3 (RN) said if a resident has a bruise/injury, the nurse needs to do an incident report, and notify the supervisor, the resident's family, and doctor. On 10/30/23 at 1:46 PM, V1 (Administrator) said no allegations or concerns about a possible injury or bruise were brought to her or investigated by her or the facility regarding R2. V1 said a wound could be caused by an injury. V1 said she, V2 (Director of Nursing/DON), and the wound care team would investigate to determine if a wound of unknown origin was caused by an injury or caused by a medical condition. On 10/20/23 at 12:04 PM, V2 (DON) said if a bruise is reported, the nurse would assess the patient and talk to the resident about possible causes of the bruise. V2 said the nurse would notify the doctor, and if no cause is found, the nurse would notify the supervisor and that supervisor would initiate an investigation. V2 said if no cause is known and the resident was unable to tell what happened, then it's considered an injury of unknown origin, and an abuse investigation is initiated by the Administrator who is the Abuse Coordinator. The nurse makes an incident report for all skin related issues, such as bruises. V2 said she reviews all incident reports and she and V1 sign off that it has been reviewed. The facility's Incident (Skin, Bruise, Other) Report Audit was reviewed for September and October (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: 145706 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 145706 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitehall of Deerfield 300 Waukegan Road Deerfield, IL 60015 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)