Health inspection·May 21, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to notify the physician of the inability to complete ordered testing timely. This applies to 1 of 4 residents (R1) reviewed for physician ordered testing in a sample of 4. Findings include: R1's Face Sheet documents R1 was admitted to the facility on [DATE] after a peri-prosthetic right hip fracture. On 5/17/2024 at 11:50 AM, R1 was sitting in a wheelchair with swelling to his right lower leg. R1 stated he fractured his right hip at home and since then his right lower leg has been swollen. R1 denied any recent increases or changes to the swelling or any additional symptoms. R1 stated he has been taking medications to prevent blood clots since he was admitted . R1's Orthopedic Treatment Note dated 5/9/2024 documents an order for a stat ultrasound of his right leg to rule out a deep vein thrombosis (DVT). R1's Right Lower Venous Ultrasound Report dated 5/13/2024 documents completion of the ultrasound and diagnosed R1 with a DVT involving the right mid superficial femoral vein. On 5/17/2024 at 12:05 PM, V2 (Director of Nursing) stated she was notified on 5/10/2024 by V4 (Nurse) that R1 needed an ultrasound. V2 stated she called their contracted radiology, and they were unable to get it completed on 5/10/2024 but were going to try to complete the testing over the weekend (5/11-5/12/2024). V2 stated the contract company did not come to complete the ultrasound until 5/13/2024. V2 stated the facility policy for stat orders is to complete as soon as possible and confirmed the timeframe in which R1's ultrasound was completed would not have met stat criteria. V2 stated she should have contacted the physician to determine next steps. R1's Brief Interview of Mental Status dated 5/11/2024 documents R1 as cognitively intact. R1's Electronic Health Record did not show that the physician was notified regarding the delay in completing the ordered stat ultrasound. The policy Clinical Protocol: Guidelines for Notifying Health Care Providers of Clinical Problems documents the guidelines are to ensure that medical care problems are communicated to the health care provider in an efficient and effective manner. These guidelines document that when the need arises the facility is to notify a health care provider regarding a change in medical conditions. The (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: 146056 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 146056 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arc at Kankakee 901 North Entrance Avenue Kankakee, IL 60901 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)