Health inspection·April 17, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to follow their policy to investigate a bruise/injury of unknown origin for 1 of 16 residents (R33) reviewed for injuries of unknown origin/abuse in the sample of 16. Residents Affected - Few The findings include: R33's care plan dated 3/2/24 showed R33 was cognitively impaired related to her diagnosis of dementia. The plan showed R33 was legally blind, hard of hearing, and required staff assistance for all activities of daily living. On 4/15/24 at 9:30 AM, R33 was asleep in a high-back wheelchair located in the doorway of her room. A nickel-sized, light purple bruise was noted to R33's right temple/forehead area. On 4/15/24 at 9:30 AM, V4 Registered Nurse (RN) was asked about R33's bruise. V4 stated, I noticed the bruise sometime last week. The CNA (certified nursing assistant) brought it to my attention because he said the bruise wasn't there the day before. She hasn't had any falls. I am not sure what happened. She can't tell us what happened. Her skin is really thin, so I just thought she hit her head on something or rubbed her head. V4 stated she did not report R33's bruise to V2 Director of Nursing/DON or V1 Administrator. V4 stated she did not document R33's bruise/change in skin condition. On 4/15/24 at 11:35 AM, V5 Family of R33 stated she was notified of R33's bruise one day last week when I was visiting. V5 stated she did observe a bruise to R33's right forehead/temple area last week. On 4/16/24 at 8:17 AM, V6 CNA stated, I noticed (R33's) bruise one day last week. It was much darker initially. I don't exactly remember what day but she didn't have the bruise the day before, so I reported it to (V4 RN). If we notice a new bruise on a resident, we are to report it to a nurse right away so they can do an investigation. (R33) can't tell us how it happened. V6 stated he did not document R33's bruise/change in skin condition. On 4/16/24 at 8:47 AM, V2 DON stated R33 did have a discoloration to her head but she bruises easily. V2 DON stated R33 could not explain what caused the bruise due to her impaired cognition. V2 stated V4 RN did not report R33's bruise to her when it was found by V4. V2 DON stated bruises or injuries of unknown origin should be investigated. V2 DON stated no investigation had been done in regard to R33's new bruise. The facility's Prevention of Abuse, Neglect, and Exploitation policy dated 1/16/24 showed, Injuries of unknown origin may be indicators of abuse which may include, but are not limited to bruising, Page 1 of 4 146007 146007 04/17/2024 Moorings of Arlington Heights 761 Old Barn Lane Arlington Hts, IL 60005

F 0607 Level of Harm - Minimal harm or potential for actual harm swelling, increased pain, changes in behaviors or physical indications that are different than the resident's baseline. Nursing staff is responsible for reporting unusual occurrences, including the appearance of bruises, lacerations, or other abnormalities observed. Upon report of such occurrence, a registered nurse is responsible for assessing the resident, reviewing the documentation, and immediately reporting the occurrence to the Abuse Coordinator (Healthcare Administrator) . Residents Affected - Few 146007 Page 2 of 4 146007 04/17/2024 Moorings of Arlington Heights 761 Old Barn Lane Arlington Hts, IL 60005

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 provide ADL (activities of daily living) assistance to residents that required staff assistance for toileting/incontinence care for 2 of 16 residents (R218, R31) reviewed for activities of daily living in the sample of 16. Residents Affected - Few The findings include: 1. R218's care plan dated 4/12/24 showed R218 required the extensive assistance of staff for toileting. The care plan showed R218 had a history of urinary incontinence. On 4/15/24 at 9:36 AM, R218 was seated in a wheelchair in his room. A strong odor of urine was noted in the room. A circular, wet area was noted to the groin area of R218's sweatpants. R218 stated, I'm wet. I called someone to help clean me up. R218 stated he had been up in the wheelchair since 6:00 AM. R218 stated he was last toileted around 6:00 AM. At 9:40 AM, V3 Certified Nursing Assistant (CNA) entered R218's room. R218 stated to V3 CNA, I'm wet. V3 CNA stated to this surveyor, He was up in the wheelchair when I started my shift this morning at 7:00 AM. I haven't toileted him yet today. V3 CNA propelled R218, in his wheelchair, into the bathroom and assisted him onto the toilet. 2. R31's care plan dated 3/29/24 showed R31 required extensive to limited assistance of staff for transferring and toileting. The care plan showed R31 had a history of urinary incontinence. On 4/15/24 at 9:45 AM, R31 was seated on the side of her bed, dressed in pajamas. A strong odor of urine and stool was noted in R31's room. When R31 was asked when she was last toileted and/or had her incontinence brief changed, R31 stated, Sometime last night. At 9:47 AM, V3 CNA entered R31's room. V3 CNA took R31 into the bathroom. As V3 pulled back the adhesive clasp on the left side of R31's brief, R31's brief immediately dropped to R31's ankles due to the heaviness of R31's brief. R31's brief was saturated with dark yellow urine and stool. R31's buttocks were pink in color. V3 CNA stated this was the first time she had toileted or changed R31 since she started her shift at 7:00 AM. On 4/16/24 at 10:20 AM, V3 CNA stated staff are to toilet or change residents every two hours. The facility's Activities of Daily Living policy dated 6/30/23 showed every resident in the facility will maintain their abilities in Activities of Daily Living which included bathing, dressing, toileting, transferring, and eating. The policy showed, Resident who is unable to carry out Activities of Daily Living will receive the necessary services to maintain good nutrition, grooming, and personal, and oral hygiene. 146007 Page 3 of 4 146007 04/17/2024 Moorings of Arlington Heights 761 Old Barn Lane Arlington Hts, IL 60005

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure the dishwasher final rinse sanitizer solution concentration was at the required level. This has the potential to affect all 51 resident's residing in the facility. The findings include: The CMS-671 dated 4/15/2024 lists total residents at 51. On 4/15/2024 at 10:15AM, a test strip was run by V8 Dietary with V9 Food Service Director present. Color of the test strip was a light pink/purple color correlating with the 10 result color on the color chart being used by staff. On 4/15/2024 at 10:15AM, V9 said the result should be 10-50 and thinks the log might be the wrong one. On 4/15/2024 at 11:03AM, V9 said the dishwasher isn't delivering the chemical and unsure why. V9 said the machine washing in that area is stopped for now and a company has been called to come look at the machine. V9 said that dishwasher is used for resident dishes in the building. V9 said the larger pots and pans are sent to the other kitchen. On 4/15/2024 at 11:55AM, V8 said she normally works in a different area. V8 said she just received some additional education today regarding the dishwasher and 10 is too low for that machine. V8 said she thought it was the wrong log for the machine. V8 said she didn't check the dishwasher in the morning, but [V7 Dietary] did. On 4/15/2024 11:59AM, V7 said she checked the machine in the morning, and it was low. V7 said sometimes the machine comes back low and sometimes high. V7 said it was low this time. On 4/17/2024 at 9:38AM, V9 said the machine was inspected and there was a crack in the line that pulls the chemical in. The facility provided Dish machine Temperature Record (Low Temperature Machine) shows chlorine rinse reference range as (50-99ppm). The facility's Dish machine Temperatures policy revised 1/24, states Low Temperature Machine Wash Temperature 120F, Final Rinse Sanitizer Solution Concentration 50-100ppm (parts per million) sodium hypochlorite (chlorine) on dish surface in final rinse (minimum of 100F). 146007 Page 4 of 4