Health inspection·January 6, 2022

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify a pressure ulcer prior to becoming unstageable and failed to ensure preventative measures were in place for 1 of 6 residents (R12) reviewed for pressure ulcers in the sample of 16. Residents Affected - Few The findings include: On 1/05/22 at 10:00 AM, R12 was sitting up in bed wearing a hospital type gown. R12 had an air mattress in place and stated, I have a sore to my backside. I got it here. I didn't have it when I came in. There is a nurse that looks at it once a week; she was here yesterday. R12 stated staff do not come in and turn R12 every couple of hours. R12 stated, Occasionally someone will come in and put a pillow behind my back. I try to turn myself in bed so it will heal. It would be nice if they did come in and help turn me. R12's Nurses Notes showed R12 was admitted to the facility on [DATE]. On 10/11/21 a CNA (certified Nursing Assistant) noted a blister to the right buttock. It was shown to the nurse practitioner during rounds, and she gave an order for treatment. R12's Wound Skin Care Assessment Tools showed: On 10/13/21 she had a stage 2 pressure ulcer to R12's right buttock that was identified by the facility on 10/11/21 and healed on 11/8/21. On 11/4/21 R12 had a facility acquired, unstageable pressure ulcer to the coccygeal area that was identified on 11/4/21. The Wound Care Physicians Note dated 1/4/22 showed, Patient presents with a wound to (R12's) coccyx. (R12) has an unstageable (due to necrosis) to (R12's) coccyx for at least 53 days duration. There is moderate serous exudate. Past Medical History: Muscle Weakness, Venous Insufficiency, Diabetes Mellitus, Hyperlipidemia, and Hypothyroidism. Off-load wound; reposition per facility protocol; Turn side to side and front to back every 1-2 hours if able. R12's Care Plan dated 10/19/21 showed, R12 is at risk for skin breakdown. Coccygeal pressure injury will heal by next review. Turn and reposition R12 in bed and in wheelchair. On 1/05/22 at 2:10 PM, V8 RN (Registered Nurse/ Wound Care Nurse) stated, On 10/8/21 is when I first saw (R12) at 9:00 AM. I put a note in the computer. V8 reviewed the Wound Care Skin Assessment Tools for R12 dated 10/13/21 that showed 10/11/21 as the date the resident's wound was assessed. V8 stated, I didn't have a chance to put in the assessment right away. I documented it on 10/13/21. The right buttock wound healed on 11/8/21. A new wound that was facility acquired was identified to (R12's) coccyx on 11/4/21. It was unstageable when it was identified because there was slough in the wound Page 1 of 6 146007 146007 01/06/2022 Moorings of Arlington Heights 761 Old Barn Lane Arlington Hts, IL 60005

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few so you cannot see the base of the wound. Staff are supposed to identify the pressure at any stage that they find it. Of course, ideally, they should find pressure at a stage I. R12 only has one wound to (R12's) coccyx now. The latest assessment was done yesterday on 1/4/21 and (R12) has an unstageable wound with daily dressing changes. The facility's Prevention and healing of pressure injuries and non-pressure related injuries policy (5/19/21) showed, Residents at the facility will not develop clinically avoidable pressure injuries. Residents admitted with pressure injuries will receive care and services to promote healing and prevent further injuries. Plan/Intervention: Implement individualized interventions to attempt to stabilize, reduce or remove each underlying risk factor. Prevention - redistribute pressure (repositioning, protecting heels.) Monitor/Evaluate: monitor and evaluate the resident's response to preventative efforts. Revise approaches as necessary. Nursing assistant observes and reports alteration in skin integrity. Notify the nurse of any change in skin condition. Nurse evaluates skin condition weekly or more often if indicated. 146007 Page 2 of 6 146007 01/06/2022 Moorings of Arlington Heights 761 Old Barn Lane Arlington Hts, IL 60005

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on interview and record review the facility failed to ensure bedtime snacks were offered to 1 of 1 resident (R11) reviewed for bedtimes snacks in the sample of 16. The findings include: On 1/5/21 at 11:00 AM, R11 stated, I am supposed to have crackers and cheese at bedtime because my doctor didn't want me to have low blood sugars during the night. It is on my meal ticket that I am supposed to have a bedtime snack, but they still didn't provide that. The Face Sheet dated 1/6/22 for R11 showed diagnoses including Type I Diabetes Mellitus with Ketoacidosis, Diabetic Autonomic Neuropathy, Acute Kidney Failure, Obesity, Gastroparesis, Chronic Kidney Disease, Hypertension, and Parkinson's Disease. The MDS (Minimum Data Set) dated 10/13/21 showed no impairment of memory and cognition. The Physician's Note dated 12/20/21 for R11 showed, History of present illness: Is a resident of the health center due to diabetic management needs. History of labile Diabetes Mellitus and recurrent Diabetic Ketoacidosis. Bedtime snack: crackers and cheese ordered per patient choice of snack when reviewed by me. R11's Physician Order Sheet for January 2022 showed to offer a bedtime snack and stated, Patient should get cheese and crackers every night at 8:30 PM or 9:00 PM. R11's Physician Order Sheet for January 2022 showed R11 receives the following: Levemir insulin 18 units in the morning and 8 units at bedtime; Novalog insulin 8 units at 8:00 AM, 12:00 PM and 5:00 PM. On 1/5/21 at 11:00 AM, during the group interview they stated, You can ask for bedtime snacks it is not a voluntary offering. They don't come around and ask if you want one. The residents in the group interview stated they would like bedtime snacks offered. On 1/06/22 at 8:50 AM, V2 DON (Director of Nursing) stated they have bedtime snacks available in the pantry and the residents have to request them. V2 stated bedtime snacks are not offered. V2 stated the residents on the first floor are alert and oriented and can ask for them. V2 stated it is different upstairs because those residents have memory problems. On 1/06/22 at 9:17 AM, V3 Director of Food Service stated, For bedtime snacks we assign a stocking sheet to a dietary aide. Then they gather what they need and deliver it to the units. We only have one resident that gets a snack all the time at bedtime because (R11) is diabetic and that is R11. (R11) is supposed to get a bedtime snack and it's delivered on (R11's) dinner tray because it is on the meal ticket. If nursing checks (R11's) blood sugar and its low nursing can grab additional snacks. Residents have to request snacks. The facility's HS (bedtime) Snacks policy (11/17/15) showed, Each resident is provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs. If necessary, in between nourishments are provided for residents as deemed necessary by the physician, registered dietician (RD) or designee, and/or at a resident's request. Bedtime snacks are in 146007 Page 3 of 6 146007 01/06/2022 Moorings of Arlington Heights 761 Old Barn Lane Arlington Hts, IL 60005

F 0809 addition to three meals served daily, with no more than 14 hours between the start of dinner and breakfast. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 146007 Page 4 of 6 146007 01/06/2022 Moorings of Arlington Heights 761 Old Barn Lane Arlington Hts, IL 60005

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to change and disinfect eye protection and face masks after caring for a COVID positive resident and before caring for COVID negative residents. The facility also failed to have signage for droplet precautions outside a COVID positive resident's room during a COVID-19 outbreak for seven of seven residents (R1, R10, R14, R30, R43, R46, R301) reviewed for infection control in the sample of 16. Residents Affected - Some The findings include: On 1/4/22 at 11:11 AM, V6 Certified Nursing Assistant (CNA) entered R43's room to assist R43 with care. R43 did not have a face mask on. V6 was within six feet on R43. R43 was in a wheelchair next to the bed. V6 exited R43's room and did not remove, change, or disinfect her goggles and N95 mask. V6 walked around the unit caring for other residents and talking with staff. R43's room is located on the second floor in a locked dementia rehab unit. The unit had seven residents residing in rooms on the unit. On 1/4/22, R43's room door had two contact isolation signs and no droplet isolation sign during observations by two surveyors. On 1/4/22 at12:40 PM, R1, R10, R30, R46 and R301 were served lunch in the second-floor rehab unit and assisted by V6 and another CNA. R14 was in bed in R14's room. V6 brought lunch into R43's room. R43's face mask was under R43's chin. V6 cut up R43's food. After exiting R43's room, V6 did not remove, change or disinfect her face shield and N95 mask. V6 was asked why she now had a face shield on (instead of the goggles she had on earlier). V6 said they (goggles) didn't fit right. V6 then pulled two pairs of goggles out of her uniform pocket to show this surveyor. They were too small. V6 said she is the main person caring for R43 but assists with other resident care as well. V6 said R14 needs two people to help R14 so she helps the other CNA turn (R14) and stuff. V6 then returned to the dining area to assist the other residents as needed. On 1/5/22 at 9:42 AM, V2 Director of Nursing (DON) said on 1/1/22, R43 complained of watery eyes and congestion. R43 tested positive and told us then R43's brother who visited R43 (did not remember the date) had since tested positive for COVID-19. R43 couldn't remember the date. That's why R43 is on our dementia rehab unit. R43 is the only known COVID positive resident on the unit and the only resident on isolation. The facility's visitor log showed R43's brother last visited on 12/12/21. On 1/5/22 at 1:25 PM, V2 said (for COVID positive residents) full PPE is required goggles or a face shield and a N95 face mask when caring for the resident. A sign outside the door is posted to tell you the resident is on precautions and what PPE to wear. Placing isolations signs is important because we have an obligation to let anyone entering the room know what PPE (personal protective equipment) is recommended to prevent transmission. Contact isolation doesn't require eye protection. Droplet isolation requires an N95 mask and eye protection. Staff keep the same mask and eye protection on while caring for all residents. They don't disinfect or change them after caring for a COVID positive resident. I am not sure if that's per facility but that is what they are doing. V2 confirmed she is the facility's Infection Preventionist. On 1/5/22 at 2:22 PM, V4 Central Supply said she does not have trouble ordering PPE and receiving 146007 Page 5 of 6 146007 01/06/2022 Moorings of Arlington Heights 761 Old Barn Lane Arlington Hts, IL 60005

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some what is ordered. V4 said she had worked at the facility for over 30 years and the facility's current supply of N95's, goggles and face shields would not be considered contingency or crisis levels. We have about three weeks of PPE in stock and that was their norm. On 1/6/22 at 09:56 AM, V2 DON said V5 Licensed Practical Nurse developed symptoms while working on the subacute dementia unit (R43's unit) tested positive for COVID-19 and was sent home some time before lunch that day. V2 said V5 is a floater and works all areas of the facility. V2 said on 12/23/21, V5 worked in the assisted living area and was unsure where V5 worked prior to 12/23/21. On 1/6/22 at 10:32 AM, V2 said the facility declared an outbreak (COVID) on 12/22/21. The following second floor rehab unit staff tested positive for COVID: On 12/24/21, V5 LPN; on 12/26/21 V6 CNA; on 12/29/21 V13 social worker; and on 12/29/21 V14 maintenance worker for the health center. On 1/6/22 at 11:00 AM, V2 said it's not appropriate to wear same eye protection and N95 while caring for COVID positive and COVID negative residents. We now changed our practice to double masking (surgical mask over N95) and disinfecting eye protection. The other practice was in place before I came (four months ago). We learn from each other so thank you for pointing this out. The facility's rapid COVID testing log showed R43 tested positive for COVID on 1/1/22. R43's physician order sheet showed contact and droplet isolation were ordered on 1/1/22. The facility's vaccination log showed R1, R10, R14, R30, R43, R46, R301, V5, V6, and V14 were fully vaccinated for COVID-19. The facility's 1/5/22 PPE supply log showed 10,080 KN95 face masks, 14,000 surgical masks, 1200 goggles, and 950 face shields. The log did not indicate the number of N95 face masks. The facility's 11/24/21 Interim PPE use and Extended/Re-use of PPE during COVID-19 showed the intent of the optimization strategies is to use these options as PPE becomes stressed, running low or if facility is out. As the supply of PPE returns to normal, standard practices should be resumed. Place TBP (Transmission Based Precautions) signage outside each resident's room. Facemasks should not be reused. Reuse of face mask is not recommended unless there used as a crisis capacity strategy in limited situations with extended use. Extended wear is considered contingency use. Reuse is considered crisis use. Disposable respirators should be removed and discarded after exiting the resident's room. Extended use refers to the practice of wearing the same PPE for repeated [NAME] contact encounters with individual or multiple residents without removing the PPE between resident encounters. Extended use may be implemented when multiple residents are infected with the same respiratory pathogen and residents are placed together in dedicated units/areas. When to discard respirators/facemasks: There are times that it becomes important to discard the mask due to significant chance of contamination. These circumstances should be cause to discard a respirator/facemask and to secure a new unused respirator/facemask. Discard following close contact with, or exit from, the care area of any resident co-infected with an infectious disease requiring contact precautions. The facility's 12/30/21 Interim Policy for Suspected or Confirmed Coronavirus showed healthcare facilities should not be using crisis capacity strategies at this time. Place signage on the use of specific PPE. 146007 Page 6 of 6