Health inspection·June 18, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident has the right to be free of neglect in one (R1) of three (R1, R2 and R3) residents reviewed in a sample of 10 residents. Findings include: R1 is a [AGE] year-old female with a diagnosis including Cerebral Infarction, Anxiety Disorder, Acute Kidney Failure, COPD, Hemiplegia and Hemiparesis affecting Left Dominant Side. R1 was admitted to the facility on [DATE]. R1 is assessed as a high risk for falls. R1 is care planned for falls. Care plan states R1 lowers herself from the bed to the floor when displaying behaviors where resident gets agitated and anxious. Floor mats are placed on both sides of bed. Bed is kept in its lowest position. R1 is also care planned for behavior of trying to get out of her bed without pulling her call light for staff assistance r/t depression and anxious behavior. R1 has a BIMS (Brief Interview for Mental Status) of 10/15. On 6/16/23 at 1:40PM R1 stated I fell off bed and lay on the mat for around two hours. The nurses were in the room but didn't put me back in the bed. I didn't get hurt. I wanted to go back in my bed, but the nurse wouldn't let me. R1 Behavior progress note 5/12/23 states Behavior: The Agency CNA reported to the writer that resident kept sliding from her bed throughout the shift. Nurse progress note 5/12/23 states: Staff Reported to NOD that Resident was on the floor mat. When asked how she got on the mat resident said I slipped from the bed to the floor. I wanted to walk and get home to my mom. Bed was in the lowest position. NOD asked resident if she hit her head, but she denied and also denied having any pain. Resident was assessed no visible bruises nor laceration noted. Resident seemed more comfortable on the mat and requested to be left on the mat and was later moved back to her bed. Nurse investigation document dated 5/12/23 states: Description: Resident informed R1's husband that she had been on floor for a few hours last night and CNAs went to help her but V5 (Nurse) stopped CNAs from assisting her to bed because she states, she was comfortable and sleeping on the mat on the floor and that she wanted resident to calm down and de-escalate before staff attempted transfer. Resident Description: R1 stated I wanted to go to bed. Upon re-interview, resident stated, I wanted Page 1 of 3 145776 145776 06/18/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0600 to get myself up Resident is a poor historian, no acute distress. Level of Harm - Minimal harm or potential for actual harm Nurse suspended pending investigation. Interview conducted with CNA, who witnessed R1 on floor (V7), V8 (POA) and V5 (Nurse). Ultimately, nurse terminated. Facility continues to adhere to policies and protocols. Facility has completed its due diligence to ensure ongoing compliance. Any alleged noncompliance has been corrected. Will continue to monitor all reported incidents for a potential pattern and for continued compliance. Residents Affected - Few Facility conducted an abuse investigation on the date of incident 5/12/23. Facility Final Abuse Investigation (5/16/23) document states including: R1 informed (Family Member) of R1 that she had been left on floor mat the evening before and nurse had prevented CNAs from assisting her back to bed. Resident assessed with no obvious injuries or compromised skin injuries. 6. Interviewed R1 who stated, I wanted to go back to bed. 7. Interviewed CNA (V4, no longer employed at facility) the nurse kept telling us not to get resident up. 8.Interviewed nurse (V5) who admitted I told the CNAs not to disturb resident as she appeared comfortable and fell asleep on the mat. 10. IDT team has provided counseling services, emotional support, and follow up to ensure emotional and mental wellbeing of resident. Resident has no complaints or concerns at this time. On 6/17/23 at 2:20PM R10 stated I was in my room and could see across the hallway. R1 was laying on the floor for at least 2 hours. I heard the nurse keep telling the CNAs not to put her back to bed and leave her on the floor. On 6/16/23 at 9:30AM V2 (Assistant DON) stated an abuse investigation was conducted on the allegation that R1 was left on the floor mat for an undetermined amount of time. R1 was found on the floor mat. R1 has a low bed and rolled onto the floor mat. R1 was assessed with no injury. During investigation the nurse involved told the CNA to leave the resident on the floor mat. The nurse was let go. The CNA no longer works here. On 6/16/23 at 9:25 AM V1 (Administrator) stated R1 was found on the floor mat by staff member V4 (CNA). V4 reported to V5 (nurse). R1 was assessed with no injury. The nurse told the CNA to leave R1 on the mat and not to get resident up. R1 lay there for an undetermined amount of time. I investigated the incident as an abuse and determined that the nurse (V5) was responsible for the incident. V5 was terminated from employment. Facility Abuse investigation was followed. V4 (CNA) has since quit working here at the facility. Facility policy titled: Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating. States: Policy Statement 145776 Page 2 of 3 145776 06/18/2023 Complete Care at Sheriden Commons 4538 North Beacon Chicago, IL 60640

F 0600 Level of Harm - Minimal harm or potential for actual harm All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Residents Affected - Few 145776 Page 3 of 3