Health inspection·April 30, 2024

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure interventions/hip precautions were used to keep a resident's left hip prosthetic in place. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 3. Residents Affected - Few The findings include: R1's EMR (Electronic Medical Record) shows that R1 was admitted to the facility on [DATE] with diagnoses including Periprosthetic Fracture around Internal Prosthetic Left Hip Joint, Difficulty in Walking, Chronic Obstructive Pulmonary Disease, Parkinson's Disease and Dementia. R1's Progress Notes dated 3/9/24 state, Received patient in bed Alert and Oriented x 1-2. Patient complained of increased pain to left hip 10/10. Oxycodone (Narcotic Analgesic) given at this time. (Physician) covering for (Primary Physician) made aware of increased pain with order for STAT X-Ray to left hip. (Portable X-Ray) made aware of STAT order. Called into patient's room upon assessment noted bloody drainage to surgical incision site and raised bump to left hip proximal to surgical incision site. Patient unable to straighten surgical left leg. New pressure dressing applied. (Physician) notified of change in drainage and raised bump with order to send patient to ER via (Private) ambulance for further evaluation. Patient notified of new orders and agreeable. Patient's wife made aware of above matter and appreciative of call. Patient left facility at 11 AM . R1's Progress Notes dated 3/9/24 state, Called (Local) Hospital, spoke to RN (Registered Nurse), patient diagnosed with dislocation of left hip and scheduled for closed hip reduction tomorrow. R1's EMR shows that he returned to the facility on 3/19/24. R1's Physician's Order Sheet shows an order dated 3/19/24 for knee immobilizer at all times and strict posterior hip precautions abduction pillow at all times. R1's Progress Notes dated 4/23/24 state, (Change in Condition) Physical Therapist noticed left leg shortened and internal rotated. Right hip more swollen and complains of pain unable to stand up. R1's Physical Therapy Treatment Encounter Note dated 4/23/24 states, Precautions/ Contraindications: WBAT (Weight Bearing as tolerated LLE (left lower extremity) [NAME] (?) at all times, posterior hip precautions, abduction pillow at all times in bed . R1's Final Report of the incident on 4/23/24 states, While at the hospital X-Ray results of the left hip showed: superior lateral dislocation of the femoral head component of the patient's left hip (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 04/30/2024 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)