Health inspection·January 29, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was transferred safely and, in a manner, to prevent resident injury. These failures resulted in a resident (R1) sustaining a leg laceration during a resident transfer. The resident was sent to a local hospital where she required fourteen sutures to repair her leg laceration. These failures apply to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. The findings include: A facility incident report and progress notes dated 1/20/25 showed R1 was found by staff to have a large, bleeding laceration to her right lateral lower leg, immediately after being transferred from her wheelchair to bed by V5 Certified Nursing Assistant (CNA). The incident report showed, Per CNA (V5) when transferring resident, her right leg scraped on the enabler piece of the resident's bed frame. The progress notes showed R1 was assessed by V4 Registered Nurse (RN) and found to have a 10 cm (centimeter) x 1 cm laceration to her leg. 911 was called. R1 was transported emergently to a local hospital for an evaluation and treatment. R1's hospital discharge notes dated 1/20/25 showed R1 was treated for a large laceration to her right lower leg that required fourteen sutures to repair. R1 was discharged back to the facility on 1/20/25. R1's progress note dated 1/21/25 showed R1 was provided with a new bed. R1's progress note dated 1/23/25 showed R1 was started on antibiotics due to developing redness to the wound on her right lower leg. R1's admission record showed R1 was admission care plan dated 1/13/25 showed R1 was admitted to the facility with diagnoses of spinal stenosis, history of falling, muscle weakness, unsteadiness on feet, and dementia. R1 was cognitively impaired. R1's transfer assessment dated [DATE] showed R1 required the assistance of 1-2 staff members for transfers. On 1/29/25 at 9:38 AM, R1 was seated in a wheelchair with a large gauze dressing noted to her right lower leg. R1 stated she didn't remember what happened to her right leg, but she remembers her leg was bleeding. R1 was unable to state when the incident happened or who was with her at the time of the incident. This surveyor's interview with R1 was limited due to R1's impaired cognition. Page 1 of 2 146007 146007 01/29/2025 Moorings of Arlington Heights 761 Old Barn Lane Arlington Hts, IL 60005

F 0689 Level of Harm - Actual harm Residents Affected - Few On 1/29/25 at 10:24 AM, V5 CNA stated, on 1/20/25, she (V5) had wheeled R1 in her wheelchair into her room to provide cares. V5 stated she transferred R1 from her wheelchair to the toilet (by herself), using a gait belt. While R1 was seated on the toilet, V5 placed R1 in a nightgown for bed. V5 stated R1 had no bleeding from her right leg at that time. V5 then transferred R1 back into her wheelchair (using a gait belt) and wheeled R1 over next to her bed. V5 transferred R1 from her wheelchair to her bed with a gait belt. V5 stated, Once I got her on the bed, I noticed her right leg was bleeding. I got the nurse and that's when we saw that she cut her leg on a screw that was sticking out of the bed. Her leg must have scraped against the screw when I put her on the bed. V5 stated, She never fell. That night, (R1) was tired. She seemed confused. This was my first-time taking care of (R1). I didn't know how she was supposed to be transferred. I asked her if she could stand, and she said yes. (R1) kept saying I'm ok so I transferred (R1) myself. I didn't realize she had hit her leg. On 1/29/25 at 12:04 PM, V4 RN stated she was called into R1's room, by V5 CNA, on 1/20/25. V4 stated she found R1 seated on the side of the bed with a bleeding wound to her right leg. V4 stated, It appeared that when (V5 CNA) was getting (R1) into bed, her leg brushed against her bed frame where a small (metal) projection was sticking out . On 1/29/25 at 12:33 PM, V2 Director of Nursing stated R1's bed was exchanged for another bed on 1/21/25 because she felt it's what caused her injury. We wanted to prevent further injury. On 1/29/25 at 1:30 PM, V8 (R1's Physician) stated he had been R1's physician for the past twenty years. V8 stated R1 was recently transferred from assisted living to skilled care due to a physical and mental decline in condition. V8 stated, She (R1) is definitely declining. She has become more confused. She (R1) can't stand up without assistance. She (R1) has severe spinal stenosis and chronic pain. V8 stated, Yes, I would expect she be transferred in a way that she does not get hurt. When she was in assisted living, she required one assist for transfers. Since being admitted to skilled care, she is bordering on needing a (mechanical) lift for transfers. She (R1) would need at least a two person assist now . 146007 Page 2 of 2