Health inspection·June 28, 2023

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 follow their policy when they did not report allegations of alleged abuse to local law enforcement for three residents. This applies to 3 residents (R1, R2, R3) in a sample of 3 reviewed for abuse allegation investigations. The findings include: 1. R1's Electronic Health Record (EHR) showed R1 was admitted to the facility on [DATE] and has multiple diagnoses including unspecified fracture of upper end of left humerus, difficulty walking, need for assistance with personal care, unsteadiness on feet, type 2 diabetes, benign prostatic hyperplasia without lower urinary tract, hypertensive heart disease, and hypothyroidism. R1's Multiple Data Set (MDS) dated [DATE] showed R1 has severe cognitive impairment. The MDS showed R1 requires extensive assistance with bed mobility, transfer, dressing, and toileting. R1's Care Plan dated June 8, 2023 showed: R1 has an Activities of Daily Living (ADL) self-care performance deficit related to activity intolerance and impaired balance. R1 has behaviors of yelling at staff and saying inappropriate comments. R1 is on opioid pain medication therapy related to humerus fracture. R1's Physical Progress Notes dated June 22, 2023, written by V4 (R1's Orthopedic Doctor), showed R1 complained the overnight staff was rough with his arm. The note showed V4's office reported the concern to the state public health agency, and R1 was encouraged to raise concerns to facility administrator. On June 27, 2023, V7 (Registered Nurse - RN) stated, he read the progress note when R1 returned from the appointment and immediately gave the note to V2 (Director of Nursing - DON). On June 27, 2023, V2 stated, when she received the note, she immediately notified V1 (Administrator). V2 stated, V1 is the one who conducted the investigation and made reports. On June 27, 2023, V1 stated, as soon as she was made aware of the allegation, she filed the initial report with the state public health agency and started the investigation. When asked when the Page 1 of 2 145804 145804 06/28/2023 Oak Trace 250 Village Drive Downers Grove, IL 60516

F 0609 Level of Harm - Minimal harm or potential for actual harm allegation was reported to law enforcement, V1 stated, they did not notify law enforcement, since there was no injury. R1's Serious Injury Incident and Communicable Disease Report dated June 22, 2023 showed Incident Category: Alleged Abuse Law Enforcement Notified: No. Residents Affected - Few 2. R2's EHR showed R2 was admitted to the facility on [DATE] and has multiple diagnoses including generalized muscle weakness, unsteadiness on feet, other lack of coordination, pain in left leg, need for assistance with personal care, history of falling, right knee arthritis, unspecified osteoarthritis, hypertension, non-ST elevation myocardial infarction, and acute ischemic heart disease. R2's MDS dated [DATE] showed R2 has moderate cognitive impairment. The MDS showed R2 requires extensive assistance with bed mobility and toileting, and total dependence for transfers. R2's Care Plan dated August 16, 2022 showed R2 has an ADL self-care performance deficit related to weakness, gait and balance deficits, and need for assistance. R2's Serious Injury Incident and Communicable Disease Report dated May 17, 2023 showed R2 alleged a Certified Nursing Assistant (CNA) threw her into bed after lunch. The report showed Incident Category: Alleged Abuse Law Enforcement Notified: No. 3. R3's EHR showed R3 was re-admitted to the facility on [DATE] and has multiple diagnoses including urinary tract infection, need for assistance with personal care, unsteadiness on feet, weakness, hypertensive heart disease, and cervical region spinal stenosis. R3's MDS dated [DATE] showed R3 is cognitively intact. The MDS showed R3 requires extensive assistance with bed mobility, transfers, and toileting. R3's Care Plan dated March 1, 2023 showed R3 has an ADL self-care performance deficit related to impaired mobility, impaired balance due to spinal stenosis. R3's Serious Injury Incident and Communicable Disease Report dated May 13, 2023 showed R3 alleged she had a bruise on her right arm because the night girl grabbed her arm and the night girls can be mean. The Report showed Incident Category: Alleged Abuse Law Enforcement Notified: No. On June 28, 2023, V1 stated, she is the Abuse Coordinator. When asked if V1 knew the requirements for reporting allegations, V1 stated, for any allegation of abuse, exploitation, or neglect, report the preliminary allegation within two hours and contact 911/law enforcement if there is injury. The facility policy titled Resident Abuse/Neglect/Exploitation and Reporting Requirements (Reviewed dated: January 21, 2019) showed: Reporting Requirements for Abuse, Neglect, Exploitation, Misappropriation or Reasonable Suspicion of a Crime: .If a covered individual reasonably suspects that a crime has occurred against a resident or person receiving care in the health center, the individual must report the suspicion to the Abuse and/or Neglect coordinator and follow the federal/state regulations. 145804 Page 2 of 2