Health inspection·February 20, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm Based on interview, and record review the facility failed to ensure a nurse reported a potential injury promptly to another nurse or physician. This applies to 1 of 3 (R1) residents reviewed for quality of care in the sample of 10. This failure resulted in R1 experiencing a delay in care/assessment and experiencing increased pain. Residents Affected - Few The findings include: On 2/20/2024 at 10:56AM, V5 Registered Nurse (RN) said on 1/27/2024 she could see [R1's] right foot stuck behind the front wheel of the wheelchair. V5 said [R1] did say oww while her foot was stuck behind the wheel. V5 said [R1] did complain of pain upon palpation of the leg. V5 said she did not see any swelling at that time. V5 said she moved [R1] down to the nurse's station she was working at to watch the patient. V5 said she was not the primary nurse for [R1] that day. V5 said she did not report the information to [R1's] primary nurse. V5 said she told V8 Certified Nursing Assistant (CNA) about the incident when (V8) came to get (R1) approximately 30 minutes after the incident occurred. V5 said she should have told [R1's] primary nurse about the incident and the resident's complaint of pain. On 2/20/2024 at 11:12AM, V7 CNA said [R1] was sitting at the nurse's station for approximately 20-30 minutes before V8 came to get [R1] and take her back to her unit. On 2/20/2024 at 1:09PM, V6 Licensed Practical Nurse (LPN) said around 3:00-3:30PM she could see [R1] sitting down by the other nursing station. V6 said she asked V8 to bring [R1] back down the hallway to keep an eye on her. V6 said V8 reported the resident was complaining of pain. V8 said [R1] had right knee swelling that was clearly visible and appeared twisted. V8 said she went to find V5 and ask her what happened. V8 said V5 told her [R1's] foot had got stuck behind the front wheel of the wheelchair. V8 said she notified V2 Director of Nursing right away and an order for an x-ray was obtained. V8 said the stat x-ray was taking a long time, up to 45 minutes. V8 said [R1] was placed back in bed via (mechanical) lift from the wheelchair and further assessed [R1's] leg. V8 said the swelling appeared to be worse after removing [R's] pants. V8 said she contacted V2 again and [R1] was sent out after calling 911 via EMS (emergency medical) transport. V6 said [R1] didn't complain of much pain while sitting in her wheelchair. On 2/20/2024 at 11:43AM, V2 said if anything changes with the resident or seems wrong there should be an assessment completed. V2 said oww would indicate a resident is hurt or something is wrong. V2 said following the assessment if any swelling or pain is noted the physician should be notified for further orders, tests, or to send the resident out of the facility. R1's progress notes dated 1/27/2024 states around 3:15PM the resident was brought back to the unit (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 3 Event ID: 146130 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 146130 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillcrest Retirement Village 1740 North Circuit Drive Round Lake Beach, IL 60073 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)