Health inspection·March 16, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a resident with an extensive need for assistance was repositioned for one of two residents (R16) reviewed for ADLs (activities of daily living) in the sample of 19. Residents Affected - Few The findings include: On 3/14/23 at 11:30 AM, R16 was observed in supine position with her head off the pillow tilted to her left side. On 3/14/23 at 12:30 PM, R16 was observed in supine position with her head off the pillow tilted to her left side. On 3/14/23 at 2:00 PM, R16 was observed in supine position with her head off the pillow tilted to her left side. On 3/15/23 at 8:30 AM, R16 was observed in supine position with her head off the pillow tilted to her left side. On 3/15/23 at 11:30 AM, R16 was observed in supine position with her head off the pillow tilted to her left side. On 3/15/23 at 12:55 PM, R16 was observed in supine position with her head off the pillow tilted to her left side. On 3/15/23 at 1:35 PM, V3 (Nurse Manager) stated that the residents who need extensive assist for ADLs are turned at least every two hours. V3 stated that the CNAs (certified nursing assistants) document it on the kiosks that are stationed near the resident's rooms on the unit, after a task is done. On 3/15/23 at 2:00 PM, this surveyor reviewed the documentation, with V3, on the kiosks. The following was documented for R16: Bladder care on 3/14/23 at 6:19 AM, Bowel care on 3/14/23 at 9:56 PM, Morning care at 6:36 AM on 3/15/23. No other documentation for R16's repositioning was documented on 3/14/23 or 3/15/23. On 3/15/23 at 2:15 PM, V3 stated that the care plan is developed by the inter-disciplinary team and the family and, that is the actual care that is carried out for that resident. V3 also stated that to ensure that an order is carried out, the staff documents it after it is done or signs off on it. V3 stated that if it's not documented, it is considered as not done. Page 1 of 4 146007 146007 03/16/2023 Moorings of Arlington Heights 761 Old Barn Lane Arlington Hts, IL 60005

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/16/23 at 1:17 PM, V7 (certified nursing assistant) stated that he repositions R16 every couple hour. V7 stated that if R16 is not repositioned, she would get a bedsore. R16's face sheet, printed on 3/16/23, showed her date of admission to the facility was on 2/18/2020 with diagnoses to include pressure ulcer of heel stage 3, Alzheimer's disease, muscle weakness, unspecified dementia, and severe protein-calorie malnutrition. R16's facility assessment printed on 3/16/23, showed R16 had severe cognitive impairment and required extensive assistance of two staff for Activities of Daily Living (ADLs). R16's POS (Physician Order Sheet) showed an order, dated 8/11/22, to reposition frequently. R16's Care Plan, initiated on 3/3/23, showed a problem of fragile skin and poor skin turgor. The interventions included, encourage to turn and reposition while in bed and in wheelchair. The facility policy number FT686, revised on 8/15/22, showed, Statement of Policy Promote the prevention of pressure injury development B. Plan/Intervention Redistribute pressure (repositioning, protecting heels etc.). 146007 Page 2 of 4 146007 03/16/2023 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 Based on observation, interview, and record review the facility failed to ensure PPE (personal protective equipment) was worn in a manner to prevent cross contamination for one of two residents (R48) reviewed for infection control in the sample of 19. Residents Affected - Few The findings include: On 3/14/23 at 11:33 AM, R48 was observed with a large sign on the door of his room that said, STOP Enhanced Barrier Precautions. The signage had illustrations to show gloves and gowns must be worn when inside the room. The sign clearly stated gloves and gowns to be worn when high-contact resident care activities were performed. The care activities included, but were not limited to transferring, providing hygiene, changing briefs or assisting with toileting, and when a urinary catheter was in use. On 3/15/23 at 10:14 AM, the enhanced barrier sign was still on R48's door. This surveyor entered the resident's room and observed V4 (CNA-Certified Nurse Aide) standing next to R48 at the toilet. R48 had a urinary drainage bag attached to his right, upper thigh. V4 was assisting R48 to transfer from the toilet to the wheelchair. V4 wore gloves but was not wearing a gown. On 3/15/23 at 1:08 PM, V4 (CNA) was questioned regarding the enhanced barrier precautions for R48 and stated, I guess it is because he has a foley catheter. My understanding is a gown is only necessary in a COVID positive room. I am a travel aide and honestly the whole thing wasn't explained very well to me. This is my first time working in this facility and I am still learning the ways here. I don't wear gowns in the enhanced barrier rooms. I just wear gloves and use hand sanitizer before and after care. At 1:54 PM, V4 approached this surveyor and stated, I did go get clarification on that sign. The nurse told me the special precautions are for any resident with a foley catheter, wounds, feeding tube, and stuff like that. We do have to wear the gown and gloves when giving care. It is an extra form of protection against spreading germs. I probably should have had a gown on earlier. On 3/15/23 at 2:03 PM, V4 donned gloves and a gown then entered R48's room. V4 explained to R48 she was going to empty the urinary drainage bag attached to his thigh. V4 opened the drainage nozzle on the collection bag and drained the urine into a beaker. V4 was touching the tip of the nozzle with her gloves, resting the nozzle on the side of the beaker, and allowing the nozzle to float in the urine container. V4 closed the nozzle with her gloves and reinserted the nozzle into the bag holder. V4 did not alcohol off the nozzle before or after emptying the urinary bag. V4 went to the bathroom and dumped the urine into the toilet. V4 noticed R48's pants were wet and decided to change the leg bag into his nighttime, full collection bag. V4 continued wearing the same gloves and got the nighttime bag from the bathroom, which she laid on the floor next to the bed. V4 disconnected the leg bag tubing and connected the nighttime bag tubing. V4 did not alcohol any tubing during the process. R48's nighttime bag quickly filled with urine. V4 opened that bag and drained the urine into the collection beaker. V4 closed the nozzle and reinserted it into the bag. Again, V4 did not alcohol off the nozzle before or after emptying the nighttime bag. R48's nighttime bag remained lying on the floor during the entire bag exchange. V4 dumped the second beaker of urine into the toilet. Returned to the bedside and touched the wheelchair, bed linens, and assisted R48 to a lying down position. V4 finally removed her contaminated gloves that she had first donned upon entrance to the room and had continued to wear during the entire catheter care process. On 3/16/23 at 11:26 AM, V2 (Director of Nurses/Infection Control Preventionist) stated gowns are to 146007 Page 3 of 4 146007 03/16/2023 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 - Few be worn inside any enhanced barrier precaution room if there is prolonged resident contact. It is important for infection control. The gowns stop the spread of any secretion or fluids. Gowns protect staff so they don't become infected with an organism that a resident may have. It is important to stop the spread of germs to other residents and/or staff members. V2 said aides should be sanitizing catheter tubing with an alcohol swab before reinserting the drainage tubing back into the collection bags. Tubing should be sanitized before connecting to a different collection bag. Gloves should always be changed between dirty and clean areas. Fresh gloves are needed before touching anything. It is important to prevent the spread of contaminates to other surfaces. Catheter bags should not be placed on the floor. It is not a clean surface. There is the potential for the spread of organisms and infections, like UTIs (urinary tract infections). R48's March 2023 Physician Order Sheet showed the indwelling catheter was ordered on 2/28/23 and the Enhanced Barrier Precautions implemented the next day on 3/1/23. The facility's Enhanced Barrier Precautions policy dated 11/1/22 states under the procedure section: EBP will be implemented for all residents with any of the following- .indwelling medical devices (e.g. central line, urinary catheter, feeding tube, .) . The policy further states: 11. PPE, gloves and gowns, will be required for all staff providing high-contact care activities which include: .changing briefs or assisting with toileting, indwelling device care or use .urinary catheter . The facility's Standard Precautions policy last review dated 9/14/22 states: Gloves should be changed during care of residents to prevent cross contamination from one body site to another. The facility was unable to provide a policy related to changing urinary catheter collection bags. 146007 Page 4 of 4