Health inspection·February 2, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a physician's order for an as soon as possible (STAT) X-ray after one resident (R1) sustained an unwitnessed fall and complained of pain in the right hip area. This failure affected one resident (R1) who was transferred to a local emergency room eighteen hours after the unwitnessed fall took place, and R1 was diagnosed with a right hip fracture. It can be determined that the reasonable person in the residents' position would have experienced psychosocial harm related to pain (eg: facial grimacing and guarding of the right leg) as a result. Findings include:R1 is a [AGE] year-old male, originally admitted on [DATE] with medical diagnoses that include and are not limited to: metabolic encephalopathy, diabetes, seizures, and major depressive disorder.According to the Minimum Data Set (MDS), R1 had a brief interview for mental status (BIMS) dated 11-21-2025, with a score of 3/15, which indicates impaired cognition and needs maximum assistance on transfers to the chair, bed, and shower. On 2/1/2026 at 12:00 p.m., V7 (Certified Nurse Assistant) said on 11/19/2025, while working the 7:00 a.m. to 3:00 p.m. shift, I was called by V16 (Certified Nurse Assistant) to R1's room. R1 was alert but confused, dependent on staff for all activities of daily living, non-ambulatory, and required a mechanical lift for transfers from the bed to a geriatric chair. Upon entering the room, R1 was observed on top of the floor mat. I do not recall whether R1 was lying on the right or left side. I assisted in transferring R1 back to bed using a mechanical lift. V12 (Licensed Practical Nurse) was in and out of the room during this time due to the emergency with R1. V7 said I did not observe any changes in R1's behavior, vocalizing as usual, saying ouch, ouch. V12 and I transferred R1 to the bed using the mechanical lift. After completing the transfer, I exited the room. I do not know what happened with R1 after that. On 1-31-2026 at 4:10 PM V12 (Licensed Practical Nurse) said I was the nurse in charge when R1 was noted on the floor, the fall took place on 11-19-2025 at 2:52 PM, I did not see when R1 fell, I was called to the room by V16 (Certified Nurse Assistant) who reported hearing a sound coming from R1's and when she went to the room R1 was on the floor mat. I went to see R1, and I saw R1 next to a low bed in top of the floor mat. I completed a head-to-toe assessment, and R1 complained of pain in the right hip area. I medicated the patient, and the provider ordered a soon as possible (STAT) X-ray of the right hip; results should be back within 4-6 hours. I also contacted the family and hospice company. On 2-2-2026 at 3:20 PM, V13 (Licensed Practical Nurse) said I was the nurse who transferred R1 to the hospital because he was complaining of pain in the right leg. R1 was supposed to have a stat X-ray, but it was not done, which is the reason I called the doctor and obtained an order to transfer to the hospital.R1's medical record documents on 11/20/2025 at 6:44AM, Resident complaints of pain to right hip (pain medication given). At 9:33AM Upon rounds resident was noted with facial grimacing and guarding of the right leg.On 2-1-2026 at 3:55 PM V8 (Medical Doctor) said, do remember R1. My expectation is for the stat x-rays to be done as soon as possible and to have results on the same day the order was given.Per local Residents Affected - Few Page 1 of 2 145718 145718 02/02/2026 Thryve of Crestwood 14255 South Cicero Avenue Crestwood, IL 60445

F 0684 Level of Harm - Actual harm Residents Affected - Few hospital emergency room documentation dated 11-20-2025 at 2:25 PM reads: (R1) presented due to fall and right hip pain, patient reportedly had a mechanical fall the day prior to presentation. X-ray of the right hip and right femur showing a superior laterally displaced commuted intertrochanteric right femoral fracture.On 2-2-2026 at 1:00 PM. V2 (Director of Nursing) said, my expectation is for the STAT x-ray to be completed within 4-6 hours. The nurse needs to notify the medical provider if any order is not followed and see what to do next. I do not remember if I was informed that the stat x-ray was not completed; the nursing team needs to let you know.On 2-2-2026 at 1:15 PM, V1 (Administrator) said, the stat x-ray needs to be completed within 4-6 hours. We do not have any policy that indicates that. The nurse is responsible for carrying out the provider's orders in a timely manner. 145718 Page 2 of 2