Health inspection·February 26, 2025

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 observation interviews and record review, the facility failed to provide emergency care for one resident (R2) who had an unwitnessed fall and complained of leg pain. This failure resulted in R2 sustaining a hip fracture that was not detected until more than twelve hours later. Residents Affected - Few Findings include: R2 is [AGE] year old with diagnosis including but not limited to: Displaced intertrochanteric fracture of right femur, unspecified fall, unsteadiness on feet, limitation of activities due to disability, other abnormalities of gait and mobility. On 2/20/25 at 11:50 PM, R2 stated, I was walking around when I fell. I told my nurse that I had fallen and my leg was hurting. I went to the hospital the next day and had surgery on my leg. Surveyor asked if R2's leg was x-rayed in the facility after his (R2's) fall. R2 stated that his leg was not x-rayed until he (R2) arrived to the hospital on the next day. On 2/20/25 at 12:20 PM, V4 (LPN/Licensed Practical Nurse) stated, the purpose of a stat x-ray after a fall is to make sure that there are no fractures or injuries. We (Nurses) need to know immediately if there is a broken bone or anything else wrong. On 2/25/25/ at 11:35 AM, V13 (ADON/ Assistant Director of Nursing) stated, I got report from the 3- 11 PM Nurse (V10) that R2 had a fallen earlier that day and that an x-ray was ordered. The X-ray Company never came during my shift. Between 6:30 AM and 7:00 AM I was told by the CNA (Certified Nurse Assistant) that R2 was complaining of pain. When I went to assess him, he was guarded, complained of pain and his right leg looked abnormally swollen. At that time, I called the NP and was given orders to send him out. V13 (ADON) said that R2 was sent to the hospital on [DATE] between 9 and 10 AM. V13 stated, Usually if a resident is complaining of pain post-fall, I will try to treat the pain and see if I can get a STAT (Now) X-ray or order to send the patient out. I would rather be safe than sorry. A patient could have a dislocation, a fracture, a tear or anything. On 2/25/25 at 1:45 PM, V12 (NP/Nurse Practitioner) stated, After a patient has sustained an unwitnessed fall and is complaining of pain, we (assigned nurse) do a head to toe assessment and check for pain and do STAT x-rays and blood work, to know if there is a fracture. V12 (NP) stated, that a STAT x-ray should be at the facility within 1-2 hours and if the x-ray is not done within the 2- hour window, she (V12) would want to have the resident sent out to the Emergency department for an x-ray and further evaluation. Page 1 of 2 146001 146001 02/26/2025 Aperion Care International 4815 South Western Ave Chicago, IL 60609

F 0684 Level of Harm - Actual harm Residents Affected - Few On 2/25/25 at 1:45 PM, V12 (NP) said, If there is an untreated fracture, the risk of blood clots can increase and can travel to the lungs causing a pulmonary embolism. There is also a risk for stroke and excruciating pain from the fracture. Facility Fall Occurrence Note dated 12/29/24 documents, R2 had an unwitnessed fall at 2000; R2 noted in bed stated to staff (V10/ LPN) that he (R2) had fallen; R2 worsening hip pain of 5 on a 1-10 scale. Progress note dated 12/29/24 at 2102 and authored by V10 (LPN) documents, on- call Nurse Practitioner called and informed of fall, V10 received orders for x-ray to left leg. Progress note dated 12/30/24 at 0749 and authored by V13 (ADON) documents, R2's pain 10 of 10 to right leg; new onset of pain; sent to hospital emergency department. Progress note dated 12/30/24 at 0829 and authored by V13 (ADON) documents, PRN (As needed medication) administered and ineffective. Progress note dated 12/30/24 a 0853 and authored by V13 (ADON) documents, R2 with increased pain to the right leg where he (R2) can't turn from side to side; R2 not allowing passive range of motion to right leg; Nurse Practitioner gave order to send to Hospital. Progress note dated 12/30/24 at 1000 documents, R2 out to Hospital via ambulance. Facility Reported Incident submitted on 1/7/25 documents, Final report; on 12/29/24, R2 stated he had a fall; on 12/30/24 R2 complained that his pain had increased; R2's Nurse (V13) called NP and obtained orders to send R2 out to the Emergency Room. Hospital History and Physical report dated 12/30/24 documents, R2 presenting to the emergency department after a fall at the nursing home yesterday (12/29/24) with persistent right hip pain. Hospital Summary dated 1/7/25 documents, R2 was seen for intertrochanteric fracture of right hip; R2 status/ post Open Reduction and Internal Fixation right hip with metal rod and screw on 1/3/25. Facility Policy titled Fall / Incident Occurrence documents, provide or obtain emergency care or first aide as needed; if incident or fall occurs between the hours of 5 PM- 7 AM; Emergency Medical Services will be notified to complete an assessment for injury and transport to local hospital for further evaluation and/or treatment if indicated. 146001 Page 2 of 2