Health inspection·December 18, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on the interview and record review, the facility failed to ensure that a resident's caregiver immediately reported a new injury of unknown origin for 1 of 1 residents (R1), who were reviewed for injuries of unknown origin in the sample of 4. The findings include: R1's current care plan showed that R1 was nonverbal, severely cognitively impaired, completely dependent on staff for all care, and unable to move her lower extremities without staff assistance due to her diagnosis of senile degeneration of the brain. A progress note for R1, dated 12/9/24, showed, Writer was notified by caregiver of bruise on left big toe, slightly swollen . Per caregiver, weekend caregiver identified the incident but did not report to the nurse on duty at the time . ordered X-ray of left foot. Site slightly warm to touch, no grimacing or pain elicited upon site palpation . R1's left foot X-ray report dated 12/10/24 showed results of acute intra-articular corner fracture at the lateral margin of the left great toe . R1's bruise/injury of unknown origin report showed R1 was unable to state what happened to her left toe due to her poor cognition. The report showed R1's power of attorney elected to not send R1 to the hospital for the injury but to have R1 remain in the facility and follow-up with R1's podiatrist. On 12/18/24 at 9:09 AM, R1 was seated in a wheelchair in her room as V3 (agency caregiver) fed R1 breakfast. This surveyor attempted to ask R1 questions but received no verbal response from R1. No spontaneous movement of R1's upper or lower extremities was noted. V3 stated R1 has a caregiver, hired by R1's family, assigned to her 7 days a week, from 8 AM-4 PM. V3 stated caregivers help facility staff provide cares to R1 but their role is primarily to provide companionship to R1 in the facility. V3 stated she alerted facility staff to R1's left toe injury on 12/9/24 as she found R1's great toe to be bruised and swollen. V3 stated, Her weekend caregiver (V18) actually noticed the bruising the day before (12/8/24) but I guess didn't tell any staff (facility) . V3 removed R1's sock on her left foot. Old, faded bruising was noted to the area between R1's left great toe and second toe. No redness, swelling, or wounds were noted to R1's left foot. On 12/18/24 at 1:38 PM, V18 (agency caregiver) stated she was assigned to R1 on 12/8/24, from 8 AM-4 PM V18 stated when she got R1 dressed that morning, she noticed R1's left great toe was bruised and swollen. V18 stated she never reported her findings to any facility staff on 12/8/24. V18 also stated she did not report R1's toe injury to her staffing agency until 12/9/24. V18 stated, I should (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 4 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 12/18/2024 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)