Health inspection·March 6, 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 and initiate investigation to determine cause of hematoma and skin tear for 1 of 3 residents (R2) reviewed for injury of unknown origin in the sample of 5. Findings include: R2's facesheet dated 3/3/2025 documents in part a diagnosis of Type 2 Diabetes Mellitus with Diabetic neuropathy, unspecified diastolic (congestive) heart failure, chronic kidney disease stage 4, and paroxysmal atrial fibrillation. R2' minimum Data Set (MDS) dated [DATE] documents A Brief Interview of mental status (BIMS) of 7 which indicates severe cognitive impairment. R2's MDS documents that R2 requires substantial /maximal assistance for sit to stand, chair-bed to chair transfer, toilet transfer, rolling left and right. R2's care plan dated 1/22/2025 documents R2 needs assistance with Activities of Daily Living (ADL'S). R2's care plan documents the following interventions; toileting- dependent on staff with gait belt, transfers sit to stand lift Assist x2. R2's care plan documents R2 is at risk for bleeding related to anticoagulant therapy atrial fibrillation. R2's care plan documents the following interventions; administer medications as ;ordered and monitor for adverse effects, monitor/document/report adverse reactions of anticoagulant therapy ,blood tinged or red urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy bruising, blurred vision, shortness ;of breath, loss of appetite, sudden changes in mental status, sudden, or significant changes in vital signs. R2's progress notes dated 2/26/2025 at 18:10 documents called to room by CNA (Certified Nursing Assistant) to observe hematoma to right inner knee with skin tear noted. Family at bedside and aware . No decreased Range Of Motion (ROM). New order received for treatment area cleansed and treatment applied. R2's progress notes dated 2/27/2025 11:04AM documents R2 sent to the hospital for evaluation. On 3/4/2025 at 10:43AM V11, CNA stated worked a double so at 6 PM was getting R2 ready for bed stared doing peri care noticed a large hard area with an open area in middle. V11 stated it was not like a skin tear, but like a hot dog how a cooked hotdog would burst. V11 stated the injury was not present on days. V11 stated she called and notified the nurse at that time. On 3/6/2025 at 10:27AM, V15 Licensed Practical Nurse (LPN) stated she first became aware of R2's Page 1 of 2 146026 146026 03/06/2025 Arc at Sangamon Valley 3400 West Washington Springfield, IL 62711

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hematoma to the right inner aspect of the right knee on 2/26/2025 evening when the CNA came and got her. V15 LPN stated R2 had dark purple bruising inner aspect of the right knee with open area. V15 stated R2's daughter was present and did not request R2 to be sent to the hospital. V15 stated she assessed R2's leg and asked R2 if anything happened to her leg and stated resident did not know. V15 stated the policy is to take a picture and and enter into risk watch. V15 stated she was unable to do this as with the new ownership she could not get in as her passwords would not work. On 3/4/2025 at 11:32AM, V2, Director of Nursing, stated if resident has an unkonwn injury it is entered into risk management and an investigation is initiated to find out origin of injury. V2 stated that V1, Administrator, trained her and told her that if you do an investigation you will find the cause of injury. V2 stated in regards to skin tear she does not have any statements as of now because R2 in the hospital. V2 was asked about the leg with the skin tear and V2 stated that is a bleed causing a hemotoma. V2 was asked if an incident report completed and initiate investigation and V2 stated no because that would be more of a change of condition. R2's record fails to document injury of unknown origin reported to (State Agency). The facility policy Abuse Prevention and Reporting-Illinois, dated revised 10/22 documents Injuries of Unknown Source: 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 injury should be classified as injury of unknown origin. The policy documents if classified as an injur of unknown source the person facts will document the injury, the location and time observed, any treatment given and notification of resident physician, and responsible party. The policy documents the (State Agency) will be notified. 146026 Page 2 of 2