Health inspection·May 23, 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 ensure an allegation of injury of unknown origin was reported to the abuse coordinator and to the State Agency (SA) for 1 (R1) out of 3 residents reviewed for abuse. Findings Include: R1's clinical records show a re-admission date of 4/8/25, with included diagnoses not limited to long term use of anticoagulants, malignant neoplasm of large intestine, cognitive communication deficit, and encounter for attention to colostomy. R1's Minimum Data Set, dated [DATE] ,shows R1 was cognitively impaired. R1's comprehensive care plan and progress notes from 4/8/25 to 5/10/25 revealed no documentation of R1's vaginal bruising and bleeding. No documentation of bruising on R1's groin and perineal area. R1's progress notes, dated 4/8/25 and 4/19/25, show R1 was noted with bruising on both lower and upper extremities. On 5/22/25 at 9:33 AM, a phone interview was conducted with V3 (Hospital emergency room Nurse). V3 stated she was the ER (Emergency Room) nurse in charge of R1 when R1 was hospitalized on [DATE]. V3 stated a head to toe assessment was completed for R1, and R1 was assessed with bleeding and bruising on her vaginal area. V3 stated she did not know where it was coming from, and R1 could not verbalize what happened. V3 stated she also noted bruising on R1's right thigh from front to back, and around her groin and perineal (peri) area. V3 stated R1 was complaining of generalized pain. V3 further stated, I called the nursing home and spoke to the nurse. I told her that there was bruising noted on [R1's] vaginal area, her right thigh, and around her groin and peri-area. I talked to the nurse who was taking care of [R1] that day. I also notified the nurse of the bleeding noted on [R1's] vaginal area. The nurse told me that she was not aware of the bruising and bleeding on her vaginal and peri-area. On 5/22/25 at 10:25 AM, V4 (Wound Care Nurse/Licensed Practical Nurse) stated R1 got bruising when she was re-admitted from the hospital in April. R1 had bruising around her right thigh front and back, her groin area, on her arms, but no bleeding. V4 stated R1 can't really say where she got the bruising from. V4 stated she informed everyone the next day during the morning meeting about R1's bruising. V4 stated she saw R1 on 5/9/25, the day before R1's hospitalization, and V4 did not see bruising or bleeding on her vaginal area. On 5/22/25 at 11:53 AM, a phone interview was conducted with V9 (Registered Nurse). V9 stated she Page 1 of 5 145659 145659 05/23/2025 Waterford Care Center, The 7445 North Sheridan Road Chicago, IL 60626

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was the nurse in charge of R1, and she sent R1 to the hospital on 5/10/25. V9 stated, When I did my rounds in the morning, [R1] was not herself. [R1] was not at her baseline. [R1] was usually alert and oriented times 2 to 3, but that morning it took a long time for her to respond. I did vitals. I called the doctor. I sent her [R1] out via 911. [R1] went to [acute hospital]. The ER nurse called me, and she wanted to know about the bruising she saw on [R1]. I did tell her that [R1] was puffy and had bruises. A couple of days after her [R1] readmission in April, I saw bruising all over her both arms, some on her both legs front and back, and her thighs. I did not see bruises on the groin. She [R1] had pitting edema, and she's [R1] on Xarelto. The nurse from the ER she said there are bruises all over [R1]. The ER nurse told me that [R1] was found with bruises on her groin and peri-area, and I told her I don't know about that. I don't remember her mentioning about the bleeding on her vaginal area. She called during 3-11 shift. It was probably around before dinner. I don't remember the ER nurse's name. I notified [V2, Director of Nursing] a week after, not immediately though. I told her [V2] about the ER nurse calling the facility asking about [R1's] bruises on her vaginal and peri-area. V9 stated the Abuse Coordinator is the Administrator [V1], and an injury of unknown origin is a type of abuse that should be reported right away. V9 stated bruises can be considered injury of unknown origin if the resident cannot tell what happen. On 5/22/25 at 1:26 PM, V2 (Director of Nursing) stated she did not receive any notification from V9 about the hospital calling the facility that R1 was found with vaginal bleeding and bruises. V2 stated that facility staff is expected to report to the supervisor immediately if they witness or hear any abuse allegation. V2 stated the supervisor will notify V1 (Administrator) to do reporting and further investigation. V2 stated bruising from an unknown source, the facility would investigate and interview staff. V2 stated when R1 was re-admitted in the facility in April, V2 received a nursing report from the hospital that R1 had bruising on her arms, bluish discoloration from right hip down to the legs, and upper arms. V2 stated she saw R1 the next day of her re-admission, and R1 had bluish discoloration on right thigh front and back. V2 stated she did not see any bruising or bleeding on R1's vaginal area. V2 stated R1 could not tell what happened to the bruises on her thigh, but R1 said her upper arms were possibly from the needles in the hospital. On 5/22/25 at 1:41 PM, V1 (Administrator) stated based on the facility's abuse prevention policy and procedure, staff must report to V1 immediately if they witness or hear any type of abuse. If V1 is not in the building, report it to the charge nurse. The charge nurse will report to V1. V1 stated the abuse investigation begins immediately. Initial reporting is sent to IDPH (Illinois Department of Public Health) immediately; less than two hours. V1 stated abuse reporting and investigation apply to injury of unknown origin, for example, an unexplained bruising on the resident. V1 stated that final reporting and investigation is done within five days. V1 stated she was notified about R1's bruising on her arms and legs that were found upon re-admission. V1 stated she was not notified about the hospital calling the facility about her vaginal bleeding and bruising. The facility's ABUSE PREVENTION PROGRAM dated 10/24, documents: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. The facility's Abuse Investigation and Reporting dated 12/24, documents: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by 145659 Page 2 of 5 145659 05/23/2025 Waterford Care Center, The 7445 North Sheridan Road Chicago, IL 60626

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 145659 Page 3 of 5 145659 05/23/2025 Waterford Care Center, The 7445 North Sheridan Road Chicago, IL 60626

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to ensure an allegation of injury of unknown origin was investigated for 1 (R1) out of 3 residents reviewed for abuse. Residents Affected - Few Findings Include: R1's clinical records show a re-admission date of 4/8/25, with included diagnoses but not limited to long term use of anticoagulants, malignant neoplasm of large intestine, cognitive communication deficit, and encounter for attention to colostomy. R1's Minimum Data Set, dated [DATE], shows R1 was cognitively impaired. R1's comprehensive care plan and progress notes from 4/8/25 to 5/10/25 revealed no documentation of R1's vaginal bruising and bleeding. No documentation of bruising on R1's groin and perineal area. R1's progress notes, dated 4/8/25 and 4/19/25, show R1 was noted with bruising on both lower and upper extremities. On 5/22/25 at 9:33 AM, a phone interview was conducted with V3 (Hospital emergency room Nurse). V3 stated she was the ER (Emergency Room) nurse in charge of R1 when R1 was hospitalized on [DATE]. V3 stated head to toe assessment was completed for R1, and R1 was assessed with bleeding and bruising on her vaginal area. V3 stated she did not know where it was coming from, and R1 could not verbalize what happened. V3 stated she also noted bruising on R1's right thigh from front to back, and around her groin and perineal (peri) area. V3 stated R1 was complaining of generalized pain. V3 further stated, I called the nursing home and spoke to the nurse. I told her that there are bruises noted on [R1's] vaginal area, her right thigh, and around her groin and peri-area. I talked to the nurse who was taking care of [R1] that day. I also notified the nurse of the bleeding noted on [R1's] vaginal area. The nurse told me that she was not aware of the bruising and bleeding on her vaginal and peri-area. On 5/22/25 at 10:25 AM, V4 (Wound Care Nurse/Licensed Practical Nurse) stated R1 got bruising when she was re-admitted from the hospital in April. R1 had bruising around her right thigh front and back, her groin area, on her arms, but no bleeding. V4 stated R1 can't really say where she got the bruising from. V4 stated she informed everyone the next day during the morning meeting about R1's bruising. V4 stated she saw R1 on 5/9/25, the day before R1's hospitalization, and V4 did not see bruising or bleeding on her vaginal area. On 5/22/25 at 11:53 AM, a phone interview was conducted with V9 (Registered Nurse). V9 stated she was the nurse in charge of R1, and she sent R1 to the hospital on 5/10/25. V9 stated, When I did my rounds in the morning, [R1] was not herself. [R1] was not at her baseline. [R1] was usually alert and oriented times 2 to 3, but that morning it took a long time for her to respond. I did vitals. I called the doctor. I sent her [R1] out via 911. [R1] went to [acute hospital]. The ER nurse called me, and she wanted to know about the bruising she saw on [R1]. I did tell her that [R1] was puffy and had bruises. A couple of days after her [R1] readmission in April, I saw bruising all over her both arms, some on her both legs front and back, and her thighs. I did not see bruises on the groin. She [R1] had pitting edema, and she's [R1] on Xarelto. The nurse from the ER she said there are bruises all over [R1]. The ER nurse told me that [R1] was found with bruises on her groin and peri-area, and I told her I don't know about that. I don't remember her mentioning about the bleeding on her vaginal 145659 Page 4 of 5 145659 05/23/2025 Waterford Care Center, The 7445 North Sheridan Road Chicago, IL 60626

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few area. She called during 3-11 shift. It was probably around before dinner. I don't remember the ER nurse's name. I notified [V2, Director of Nursing] a week after, not immediately though. I told her [V2] about the ER nurse calling the facility asking about [R1's] bruises on her vaginal and peri-area. V9 stated the Abuse Coordinator is the Administrator [V1], and an injury of unknown origin is a type of abuse that should be reported right away. V9 stated bruises can be considered injury of unknown origin if the resident cannot tell what happen. On 5/22/25 at 1:26 PM, V2 (Director of Nursing) stated she did not receive any notification from V9 about the hospital calling the facility that R1 was found with vaginal bleeding and bruises. V2 stated facility staff is expected to report to the supervisor immediately if they witness or hear any abuse allegation. V2 stated the supervisor will notify V1 (Administrator) to do reporting and further investigation. V2 stated bruising from an unknown source, the facility would investigate and interview staff. V2 stated when R1 was re-admitted in the facility in April, V2 received a nursing report from the hospital that R1 had bruising on her arms, bluish discoloration from right hip down to the legs, and upper arms. V2 stated she saw R1 the next day of her re-admission, and R1 had bluish discoloration on right thigh front and back. V2 stated she did not see any bruising or bleeding on R1's vaginal area. V2 stated R1 could not tell what happened to the bruises on her thigh, but R1 said her upper arms were possibly from the needles in the hospital. On 5/22/25 at 1:41 PM, V1 (Administrator) stated based on the facility's abuse prevention policy and procedure, staff must report to V1 immediately if they witness or hear any type of abuse. If V1 is not in the building, report it to the charge nurse. The charge nurse will report to V1. V1 stated the abuse investigation begins immediately. Initial reporting is sent to IDPH (Illinois Department of Public Health) immediately less than two hours. V1 stated abuse reporting and investigation apply to injury of unknown origin, for example, an unexplained bruising on the resident. V1 stated final reporting and investigation is done within five days. V1 stated she was notified about R1's bruising on her arms and legs that were found upon re-admission. V1 stated she was not notified about the hospital calling the facility about her vaginal bleeding and bruising. The facility's ABUSE PREVENTION PROGRAM dated 10/24, documents: Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in a investigation. For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence or injuries over time. The facility's Abuse Investigation and Reporting dated 12/24, documents: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 145659 Page 5 of 5