Health inspection·April 30, 2024

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 an injury of unknown origin to the State Agency for one resident (R1) of three residents reviewed for falls. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated/revised 12/5/22 documents: 6.) Identification of Abuse, Neglect, and Exploitation - The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators: c.) Physical injury of a resident, of unknown source. Physician Order Summary Report dated 4/2024 indicates R1 was [AGE] years old with diagnoses that include Long Term/Current Use of Anticoagulants, Personal History of Venous Thrombosis and Embolism, Unspecified Rotator Cuff Tear or Rupture of Left/Right Shoulder, Pain in Left Shoulder. Had been receiving Coumadin (anticoagulant) 2mg (milligrams) MAR (Medication Administration Record) indicates R1 received Coumadin (anticoagulant) 2mg (milligrams) in the evening for Afib (Atrial Fibrillation). Incident Report dated 4/19/24 at 5:25pm indicates R1 was sent to the Emergency Department due to swollen left breast. Report indicates left breast area was hard, no redness or warmth.; no discoloration noted. R1 had been complaining of left arm pain. Report/Resident Description indicates I haven't fallen or had any issues. It just started hurting more after my shower. Report indicates R1 had been on long-term anticoagulant therapy. Incident Report Notes dated 4/22/24 indicates only incident for R1 was a fall that occurred on 4/10/24. Note indicates an X-ray and doppler of R1's ankle was performed after R1's fall with negative results for both tests. Incident Report note dated 4/22/24 indicates Nurse notified physician of increased edema and family's request to have R1 sent to hospital for evaluation. Progress Notes dated 4/19/24 at 6:50pm indicates R1 was transported to the hospital at that time. Page 1 of 3 145646 145646 04/30/2024 Loft Rehab of East Peoria, The 900 Centennial Drive East Peoria, IL 61611

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Progress Note dated 4/20/24 at 4:25am indicates R1 was admitted to the hospital with diagnosis of chest wall hematoma. Hospital ED (Emergency Department) Report dated 4/19/24 indicates R1 presented to the ED for evaluation of left chest wall/breast region. Report indicates Apparently, this morning (R1) showered and was unsteady on her feet, went to grab onto the CNA (Certified Nurse Assistant) and (R1's) chest wall came into contact with the nurses shoulder. Report indicates as the day went on, (R1) developed increasing pain and swelling to the chest wall. Report indicates As a side note, (R1) has been reporting pain in her left foot and ankle region. Family relates that X-rays were done at the nursing home, but results were unknown. ED Report Physical Exam indicates Findings: Bruising (there are multiple areas of bruising noted to the upper arms, left chest wall, and left foot present. Swelling and tenderness of left foot. ED Report CT (Computed Tomography) Chest with Contrast dated 4/19/24 at 10:07pm Indication: [AGE] year-old with given clinical history of Chest trauma, blunt trauma. ED CT findings indicate Chest all soft tissues: there is a large left-sided chest wall hematoma measuring up to 8.2cm (centimeter) x 11.6cm in greatest axial dimension. ED CT Impression: A critical finding has been communicated to physician. ED left ankle and left foot X-ray results indicate a fracture at the base of R1's 5th metatarsal. ED Report dated 4/19/24 at 10:53pm indicates (R1's) CT returned and there is a large hematoma to the left chest wall. There were foci of contrast noted in the posterior aspect of the hematoma worrisome for active hemorrhage. Report indicates (R1), and family are amenable to proceeding with FFP (Fresh Frozen Plasma) as well as Vitamin K ordered. ED Report dated 4/19/24 at 11:09pm indicates (R1) would receive conservative management and would receive 3 units of FFP and management with ice. Hospitalist admission Report dated 4/19/24 at 7:12pm indicates: Patient Active Hospital Problem List: 1. Left chest wall hematoma secondary to injury at nursing home where a worker's shoulder hit the left chest wall on transfer. 2. Right foot metatarsal fracture: unclear etiology however (r1) has bruised foot. 3. Acute blood loss/chronic anemia. Report indicates On assessment (R1) is unable to tell me how she hurt herself. She does not remember falling, she does not know how she hurt her foot. She is able to tell me that her chest significantly hurts over the area of the hematoma. On 4/26/24 at 11:10am V1, Abuse Coordinator stated that both V2, DON (Director of Nursing) and herself reviewed R1's hospital records on Monday 4/22/24 and after speaking with V11, Family and V12, 145646 Page 2 of 3 145646 04/30/2024 Loft Rehab of East Peoria, The 900 Centennial Drive East Peoria, IL 61611

F 0609 Family - who stated they believed R1's chest wall hematoma was due to her long-term anticoagulant use made the decision not to report the incident to the State Agency. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145646 Page 3 of 3