Health inspection·April 18, 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 an abuse allegation to Illinois Department of Public Health (IDPH) for one resident (R1) out of 4 residents reviewed for abuse. Finding include: R1's Face sheet documents that R1 was admitted to the facility on [DATE] with diagnoses not limited to: Toxic encephalopathy, unspecified abnormalities of gait and mobility, other reduced mobility, type 2 diabetes mellitus without complications, acute kidney failure. Essential (primary) hypertension. Minimum Data Set Section (MDS) section C (dated [DATE]) documents that R1 has a Brief Interview for Mental Status (BIMS) score of 5, indicating that R1 has a severe cognitive impairment. Care plan (dated 04/14/2025) documents that R1 is noted with potential communication deficits- may have difficulty completing her thoughts, trouble with word choices. On 04/15/2025 at 11:06AM, during a complaint investigation survey, surveyor inquired for V1 (administrator) to bring the surveyor the facility reportable binder. At 11:31AM, surveyor received the reportable binder and after reviewing it, surveyor noted that R1's abuse allegation from 03/20/2025, was not in the facility's reportable binder. Surveyor interviewed V1 to determine why the reportable was not submitted to the state agency. On 04/15/2025 at 11:35AM, V1 (administrator) stated, R1 was admitted to the facility on [DATE]. On 03/20/2025, when R1's family came to the facility to visit R1, they noticed the discoloration to R1's left eye. V2 (director of nursing) and I, went to assess R1 and R1's son and V5 (R1's daughter) were present during the assessment. During the assessment, I saw R1 with a discoloration to the left eye, which looked different from the right eye. R1's skin is of dark complexion, and the discoloration did not appear red. We asked the resident what happened. R1 mentioned that during the ambulance transport to the facility, the night prior, something fell on R1's head inside the ambulance. R1 was not sure what fell on her head. R1 was explicit about saying that they did not mean for anything to fall on R1. R1 mentioned that the paramedics put back whatever fell on R1's head. R1 is alert and oriented. I told the family that I would call the ambulance for the ambulance to start the investigation. I did not have the ambulance transport form. I had to ask the hospital's case manager for the name of the ambulance company. I contacted the ambulance company and I spoke to the manager, and I informed them of the allegation that something had fallen on R1's head during transportation. The next day, on 03/21/2025, the manager from the ambulance company called me back and informed me that there Page 1 of 2 145844 145844 04/18/2025 Pearl of Montclare, The 2833 North Nordica Avenue Chicago, IL 60634

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was no such incident noted on their end. I had asked the manager for a written report because I wanted to provide the ambulance report to R1's daughter. The manager informed me that he would send the report. R1 was very specific about how R1 obtained the discoloration under her eye. Nobody noted the discoloration under R1's left eye when she was admitted to the facility because R1 admitted to the facility late, round 9:30PM. R1 reported the ambulance incident in front of her son and daughter. R1's physician was notified, and the physician ordered an x-ray. The x-ray result was negative. The report from the ambulance company came much later, on 04/01/2025. The daughter received the report. There was not much follow up because shortly after that, R1 went to the hospital on [DATE] and returned to the facility on [DATE]. I conducted an investigation of R1's left eye discoloration. I interviewed the resident, as part of the investigation. If R1 was not able to tell me what happened to her eye, or if R1 did not remember how it happened, then it would trigger an abuse investigation and I would report it to the state agency (IDPH). Based on the interview with the resident, I did not deem it as an abuse allegation. R1 was adamant that it was not intentional and that something fell on her head inside the ambulance. I informed the ambulance company to conduct their own investigation. I have the origin for the discoloration on R1's eye, so we know how it happened and that the patient stated that it was not intentional. When the ambulance company denied that the allegation occurred, I did not feel that I should report it to the state agency, and the resident was at the hospital at the time. R1 still has the same discoloration under her left eye that she had on 03/20/2025. The family mentioned that the discoloration was not her usual discoloration. I saw R1 yesterday, (04/14/2025) and it looks the same as it looked on 03/20/2025. Ambulance Investigation Report (dated 04/01/2025) documents in part: After the completion of the investigation, there was no incident found during the transportation and/or transfer of the patient while in the care of the ambulance crew. Injury Investigation Policy (dated 10/03/2020) states in part: It is the policy of the facility to investigate any unexplained resident injury. Abuse Prevention Policy (undated) states in part: After an allegation of abuse, neglect, mistreatment, misappropriation of resident property, or exploitation, the administrator or designee will initiate an investigation into the allegation. (C.) Initial report. An initial report to the State licensing agency, Illinois Department of Public Health, shall be made immediately after the resident has been assessed and the alleged perpetrator has been removed. 145844 Page 2 of 2