Health inspection·December 22, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12-21-2024 at 2:00 pm V12 (Registered Nurse) said, R1 had a fall on the 3-11 shift. I worked on the 11-7 shift. R1 complained of pain in the right hip, the MD ordered a STAT x-ray, the x-ray company told me that they could not come to do it during the night shift, I told V2 (Director of Nursing). I did not report to the doctor. I documented the vital signs, but I did not document the pulse oximetry, I do not remember if took it or not. I should have done it. I know I have to do neurological (neuro) checks. On 10-28-2024 at 5:00 am R1 was provided incontinence care, R1 complained of pain in the right hip. On 12-21-2024 at 2:50 pm V12 said, I should have called the doctor to let him know the delay on the STAT x-ray and obtain further orders. I need to remember to complete the neuro checks after an unwitnessed fall, I am sorry, it was my fault. On 12-21-2024 at 12:55 pm V7 (Registered Nurse) said, R1 was able to walk using the rolling walker with one person's assistance and the wheelchair the rest of the time, able to feed himself after the tray was set up. R1 was alert and oriented to self and confused. R1 was not able to use the call light, R1 will get anxious very easily and will not have an understanding of his physical limitations. I kept him by the nurse station all the time for people to keep an eye on him since he was a high risk for falls. I do remember on Monday, 10-28-2024 I was working during the first shift, I did my rounds to make sure the patients were doing well when I took reports from the night nurse. R1 was in his bed, I saw that R1 was having labored breathing and difficulty to aroused, his right hip was noted to be red, and R1 complained of pain. I did a pulse oximetry (pulse Ox) and the machine read 66%, according to EMR (electronic medical records) Vitals Blood Pressure 125/65 T 97.7 Heart rate 88 Respirations 26. I increased the oxygen to 10 liters via mask I called the doctor and I sent R1 via 911. V12 (Registered Nurse) from the night shift, said the right hip x-ray was not done because the company was not able to come during the night. We nurses, need to take a full set of vital signs including blood pressure, heart rate, temperature respiratory rate, and oxygen saturation, we need to complete the neurological (neuro)checks to make sure the patient is not having any changes in condition. The neuro checks are done: every 15 min for the first hour, then every 30 min x 2, every hour x 4, and every 8 hours for the remaining time to complete the 72 hours. On 12-21-2024 at 12:20 pm V4 (Registered Nurse) said, when any of my patients have an unwitnessed fall, I am responsible for making sure to evaluate the patient, we are not to move the patient if there is any complaint of pain, we must call 911 as a nursing intervention. I will complete a head-to-toe assessment, if the patient is complaining of hip, or leg pain the nurse needs to make sure the extremities are not having any shortening. I need to take a full set of vital signs including blood pressure, heart rate, temperature respiratory rate, and oxygen saturation, we need to complete the neurological (neuro)checks to make sure the patient is not having any changes in condition. The neuro checks are done: every 15 min for the first hour, then every 30 min x 2, every hour x 4, and every 8 hours for the remaining time. The nurse is responsible for notifying the medical provider: Nurse practitioner or medical doctor and the Director of Nursing if any of the provider's orders cannot be followed. On 12-21-2024 at 12:45 pm V6 (Registered Nurse) said, R1 was confused and forgetful. We as nurses need to make sure to follow the doctor's orders and if we are not able to carry the order out, we need to call and report to the doctor for any further orders. If the patient has an unwitnessed fall, we need to make sure to complete a complete body assessment and start neuro checks, that is the only way to see if the patient is having any change in condition. Neuro check if I remember correctly needs to be done every 15 min for the first hour, then every 30 min x 2, every hour x 4, and every 8 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 2 of 3 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 145724 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Addolorata Villa 555 McHenry Road Wheeling, IL 60090 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 On 12-21-2024 at 1:40 pm V3 (MDS Coordinator) said, if the patient has an unwitnessed fall, the nurse must start neuro checks, complete the fall, and pain assessments, call the medical doctor, and update the care plan. The neuro checks are done to make sure the patient does not have any changes in their mental status. The nurse needs to document in the electronic medical record any changes in condition, falls, incidents, and any monitoring. R1 was a nice patient, very forgetful and unable to use the call light consistently due to his cognitive status. R1's hospital records read: primary diagnosis on 10-28-2024 at 8:03 am Acute and Chronic respiratory failure with hypoxia. X-ray of pelvis dated: 10-28-2024 at 10:59 am indicated pain in the right hip, trauma. findings: there is a fracture through the right lesser trochanter and lucency through the intertrochanteric portion of the hip. Orthopedic note dated: 10-28-2024 at 5:07 pm reads: right lower extremity is externally rotated, mild swelling of the hip and proximal leg. On 12-21-2024 at 3:10 pm V15 (Primary Medical Doctor) said, my expectation is for the nurse at the long-term care facility to call me when a STAT X-ray is not done. I need to be called when I give an order and is not able to be completed. I was never notified that the STAT X-ray was not done for R1. R1 was a very complex patient, he had cardiac and respiratory issues among many other issues. On 12-22-2024 at 5:20 pm V2 (Director of Nursing) said, my expectation for the nurse to document in the medical records when the patient has any falls, to notify the medical provider, to document in the patient's medical record if any new order is received and carried out. The standard of practice requires the nurse to communicate with the doctor if the order is not carried out. It is unacceptable not to have complete medical record including and not limited to when the patient has a fall. The nurse is responsible to take a full set of vital signs and to monitor the patient's condition. We do not have any policy on neurological checks, we do not have any policy on carrying out doctors' orders. V2 presented a policy dated: 3-21-2024 and titled: documentation in medical records reads: documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145724 If continuation sheet Page 3 of 3