Health inspection·February 10, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report injury of unknown origin for one of four (R2) residents, reviewed for reporting, in a sample of 5. Findings include: The facility's policy, Abuse Prevention Policy, dated 9/29/2022, documented, A. Must ensure that all alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours . 1. R2's Minimum Data Set (MDS) dated [DATE], documented that her cognition was severely impaired. R2's Physician's order sheet, dated 2/2025, documented diagnosis of dementia and atrial fibulation. It also documented orders for Adult Low Dose Aspirin (aspirin) 81 mg tablet, delayed release 1 tab oral, once a day and Eliquis (apixaban) 2.5 mg (milligram) tablet twice a day. R2's Care Plan, dated 6/11/2024, documented, Approach: Protect resident from injury/trauma. It continues, Approach: Observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temp, pain in joints, abdominal pain, epistaxis). R2's Care Plan, dated 2/26/2024, documented, Approach: Report any suspected of abuse/neglect to administrator immediately. R2's Progress note, dated 02/02/2025 at 02:09 PM, V2, ADON, documented,[Recorded as Late Entry on 02/04/2025 02:11 PM] While giving meds to resident this afternoon, writer noticed light bluish V shaped bruise to resident's upper right forehead. Writer investigating possible cause, interviewing all staff. Resident independent and with confusion, resident not sure what happened when asked about bruise. R2's Progress note, dated 02/03/2025 at 01:01 PM, V3, LPN, documented, Not acting her normal self. Had to be feed. Would not even open her mouth for meds. (medications) Stares off. Episodes of crying. No verbal response. Noted bruise to forehead. (V10, R2's Physician) notified and will send to ER (Emergency Room). POA notified. (Local Ambulance) called. Call report to hospital. R2's Skin integrity events, dated 2/2/25, documented, PHYSICAL OBSERVATION: Location of Bruise and Size of Bruise right upper forehead 3cm (centimeter) x 3cm at biggest parts V shaped. It continues, Page 1 of 2 145502 145502 02/10/2025 Taylorville Care Center 600 South Houston Taylorville, IL 62568

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Activity during Bruise Occurrence Dressing Other - Residents tends to rest head on table at time causing indentions, It continues, Notify MD/NP/PA (Physician/Nurse Practitioner/Physician Assistant) immediately by phone or beeper for any of the following. Bruising of unknown origin. R2's Local Ambulance run sheet, dated 2/3/2025, documented, Mental status: Pt (patient). has history of dementia and is alert to self. It continues, HEENT: (Head/Ears/Eyes/Nose/Throat) Old contusion noted on Pt. face proximal to the forehead. Dried blood noted in both nostrils of nose, Nursing home staff is unsure of what happened or why the bruising and blood was present when asked. It continues, Old bruising was noted on Pt. head proximal to the right side of forehead, dried blood was noted in both of Pt. nostrils. Pt. was asked by EMS (Emergency Medical Systems) crew if anything was hurting her. Pt. continued crying and stated that she did not want to tell on anyone. R2's Local hospital, History and Physical, dated 2/3/2025, documented, ENT: (Ears/Nose/Throat) normal. Nose normal. (Bruise to the midline forehead. Dried blood in the anterior right nares). It continues, History of Present Illness: [AGE] year old female with a past medical history of dementia systolic heart failure, CKD (Chronic Kidney Disease) stage 3, depression, hypertension, CAD (Coronary Artery Disease), Afib on Eliquis, GERD (Gastro Esophageal Reflux Disease) restless legs syndrome. At baseline patient is pleasantly confused who presented to emergency room for ECF for altered mental status. Nursing home staff report onset of alteration today. Patient is not able to feed herself, take her medication or responding to questions which she normally does. EMS noted bruise on forehead and patient withdraws to touch. emergency room contacted (State Agency) due to EMS is concern of elder abuse. On 2/6/2025 at 8:50 AM, V2, Assistant Director of Nurses stated that she noticed on 2/2/2025 a light bluish V shape bruise to R2's right side of her forehead and it was approximately 3cm x 3cm. She continued to state that on 2/3/2025 that morning she had seen R2 and she did not have dried blood in her nostrils. She continued to state that she was still investigating R2's bruise she was still interviewing staff about it and they did not know at the time about what had happened. V2 stated when asked who reports injuries of unknown origin or reportables to the State Agency, she stated that either the administrator or she does but she did not report R2's bruise to her forehead. On 2/6/2025 at 10:00 AM, V1, Administrator, stated that on 2/2/2025 R2 had blood in her nose and on her stuffed animal and she was speaking with the family and they weren't concerned about it since she is on a blood thinner. Asked V1 if she reported, to the State Agency, she stated that R2 was not sent to the hospital for the bruise to her right side of her forehead and she was sent because she had a change in her level of consciousness probably because of her urinary tract infection and her cat scan's all came back normal. 145502 Page 2 of 2