Inspection·December 11, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to complete ongoing assessments of a resident after the resident had sustained a fall with injury for 1 of 3 residents (R2) reviewed for quality of care in the sample of 3. Residents Affected - Few The findings include: R2's current care plan showed R2 was at high risk for falls due to her history of repeated falls and her impaired cognition related to her diagnosis of dementia. R2 was dependent on staff for cares. R2's fall investigation report dated 11/29/24 showed R2 sustained an unwitnessed fall out of bed on 11/28/24 around 4:00 AM. R2 was immediately assessed by staff and found to have no complaints of pain or obvious injuries. The report showed R2 began complaining of left leg pain on 11/29/24. An X-ray of R2's left leg was completed in the facility on 11/29/24. R2's X-ray report dated 11/29/24 showed R2 had a proximal left femur fracture. The facility attempted to send R2 to the hospital for an evaluation but V18 (R2's family/power of attorney/POA) did not want R2 hospitalized . R2 remained in facility with orders for pain management and order to follow up with an orthopedic physician. R2's post fall assessments. including neurological flow sheets and 72 hour post-fall assessments were reviewed. The assessments showed R2 was initially assessed by staff immediately after her fall on 11/28/24. R2 was assessed by staff, as per facility protocol, from 4:15 AM -10:45 AM on 11/28/24. R2's electronic medical record showed no post-fall assessments were completed on R2 from 11:45 AM-11:59 PM on 11/28/24. On 12/11/24 at 1:30 PM, V2 Director of Nursing (DON) stated any resident that hits their head as a result of a fall or any resident that sustains an unwitnessed fall (as R2 did), staff are to complete a neurological (neuro) assessment on a resident immediately after a fall, then every 15 minutes times 4, every 30 minutes times 4, every hour times four, and then every 8 hours for the remainder of the 72 hours post-fall. V2 stated facility staff are also to assess a resident and complete a 72 hour post-fall assessment, every 8 hours, after any resident falls in the facility. V2 confirmed no neurological assessments or 72 hour post-fall assessments had been completed on R2 from 11:45 AM-11:59 PM on 11/28/24. The facility's Neurological Assessment policy dated 3/2021 showed, Neurological assessment is performed following an injury resulting in actual or suspected head trauma or according to order . Neurological assessment is performed for 72 hours. The accepted time frame is as follows: every 15 minutes X 4 then every 30 minutes X 4 then every 1 hour X 4 then every 8 hours for the remainder of the 72 hours . Five key neurological checkpoints should be monitored and recorded on the Neurological Assessment Flow Sheet. a) Level of Consciousness b) Pupil Response c) Motor Functions d) Pain Response e) (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 5 Event ID: 146159 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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)