Health inspection·May 3, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure a skin tear was reported and treatment initiated for 1 of 18 residents (R34) reviewed for necessary care and services in the sample of 18. Residents Affected - Few The findings include: On 5/1/23 at 1:10 PM, R34 had a skin tear on her left forearm. The area had a small amount of blood present. There was a small amount of blood on R34's incontinence pad. V12, Certified Nursing Assistant (CNA) said, Hmm, I wonder where that is from? On 5/2/23 at 2:39 PM, V14 (CNA) said that if a skin tear is seen, it should be reported to the nurse right away. At 2:44 PM, V13, Licensed Practical Nurse (LPN) said that if a CNA notices a skin tear, it should be reported to the wound nurse or the nurse so the nurse can follow up on it and get orders from the doctor. V13 said that the findings would be documented in the resident's medical record and orders placed. On 5/2/23 at 10:29 AM, V3 (Wound LPN) said that she is not aware of any new skin tears for R34. V3 said that the typical treatment for a skin tear is a dressing until it is healed. At 11:41 AM, V3 said that the nurse or herself should have been notified right away about the skin tear so it could be assessed and treatment started. On 5/3/23 at 10:00 AM, V3 said that she had looked through R34's medical record and could not find any documentation regarding R34's skin tear to her forearm besides the information that she had documented on 5/2/23. R34's Electronic Medical Record does not document anything about her current left forearm skin tear until 5/2/23. R34's Nursing Notes dated 5/2/23 at 11:19 AM shows, 'Partial flap skin loss skin tear R34's Physician's Order Sheet shows an order dated 5/2/23 for, Cleanse skin tear to left arm (wrist area) with soap and H2O or wound cleanser. Apply Xeroform and cover with foam dressing every night shift every Monday, Wednesday, Friday for skin tear. R34's Skin Tear Care Plan shows, If skin tear occurs, treat per facility protocol and notify MD, family. The facility's Skin Tears-Abrasions and Minor Breaks, Care of Policy revised September, 2018 shows, Obtain a physician's order as needed. Document physician notification in the medical record Generate Non-Pressure form and complete. If he wound is bleeding, gently apply a compress with pressure over the wound and reinforce with compress as needed to control any bleeding. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. Cleanse the wound with ordered cleanser. Apply ordered dressing. Complete in-house investigation of causation. Generate. Document physician and family notification, and resident education in medical record. When an abrasion/skin tear/bruise is discovered, complete a report of Incident/Accident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145278 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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** 2. On 5/1/23 at 9:15AM R83 was lying in her bed on a low air loss mattress. The bed was in the lowest position and there was a mat on the floor next to the bed. R83 was sleeping soundly. Residents Affected - Few On 5/3/23 at 10:35 AM R83 was lying in her bed, awake with the television on. R83 was able to say hello to Surveyor but not able to answer most simple questions. R83's Order Summary Report for May 2023 shows that R83 has diagnoses including Alzheimer's Disease, H/O Breast Cancer and Psychotic Disorder with Delusions. R83's Treatment Administration Record for December 2022 shows that R83 had an order to: Cleanse coccyx with wound cleanser and apply Zinc Oxide every shift for skin. This order is dated 11/7/22- 12/20/22 (when the Stage 3 wound was first documented ). R83's Nurse Progress Notes dated 12/20/22 state, Noted to have stage 3 to coccyx: approximately 2.5 cm by 1 cm pale pink non granulating. (R83) has had a recent DX of COVID, poor appetite and fluid intake. Spending more time in bed. (Physician) updated, message left for guardian. Referral to dietician, currently working with therapy. R83's Wound Report dated 12/20/22 (First Assessment) states, Risk Factors: Unable to comprehend related to dementia. Adding Hydrocolloid (dressing) every 3 days and as needed. Adding of prostat (supplement) 30ml twice a day for 14 days. CBC/CMS (lab work) scheduled. Referral to wound care MD, Incontinence care, offloading. Pressure redistribution mattress, cushion to wheelchair. Contributing factors:Recent diagnosis of COVID with decline in mobility, poor appetite/fluid intake. R83's Specialty Physician Wound Evaluation and Management Summary dated 12/22/22 shows that R83 has a Stage 3 Pressure Wound to her coccyx- full thickness. The wound measure 3.2 x 2.0 x 0.2 cm and has light serous exudate. On 5/2/23 at 11:40 AM V3 (Assistant Director of Nursing) stated, As soon as they (CNAs) find something (on a resident's skin) they are supposed to let the nurse know. On 5/3/23 at 10:20 AM, V3 was asked why R83's wound was not assessed until it was a Stage 3. V3 stated, We had an inservice about that. I know (R83) doesn't eat and she is resistive to care. They are not reporting things. Skin can break down really fast and I think she is on an every shift skin check. I think it was a Tuesday and the wound MD saw her on Thursday. The facility policy entitled Prevention of Pressure Ulcers/Injuries dated July 2017 states, Evaluate , Report and Document potential changes in the skin. Based on observation, interview, and record review the facility failed to identify a pressure ulcer before becoming a stage 3 pressure ulcer and failed to implement interventions to prevent pressure ulcers for 2 of 6 residents (R34 and R83) reviewed for pressure ulcers in the sample of 18. The findings include: 1. R34's Minimum Data Set assessment dated [DATE] shows that she requires extensive assistance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145278 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bed mobility, is at risk for developing a pressure ulcer and currently does not have a pressure ulcer. R34's Weights and Vitals Summary shows that on 5/1/23 her weight was 111 pounds. On 5/1/23 at 9:33 AM, R34 was sitting up in a chair. At 1:10 PM, Incontinence care was provided to R34. R34's buttocks was reddened and R34 had a four inch reddened area along her spine. R34's low air loss mattress was set to a patient weight of 360 pounds. On 5/2/23 at 10:29 AM, R34 was laying in bed. R34's low air loss mattress was still set to 360 pounds. On 5/1/23 at 1:35 PM, V12, Certified Nursing Assistant (CNA) said that she had gotten R34 up around 6:30 AM and put her back to bed to change her around 8:10 AM and then got her back up in the chair and she has been up in the chair since then. On 5/2/23 at 10:29 AM, V3 (Wound Nurse) said that R34 has an air mattress to prevent pressure ulcers from developing. V3 said that R34 has a history of pressure ulcers on her spine but does not currently have any pressure ulcers. V3 then looked at R34's spine and said that she now has a stage 2 pressure ulcer on her spine. V3 said that R34 was tried on a regular bed after her ulcers healed but she broke down again right away so she was switched back to an air mattress. V3 said that an air mattress should be adjusted based on the resident's weight. V3 said that if it is set to a higher weight, it is not giving the resident to appropriate pressure relief. V3 said that any new reddened areas should be reported to herself or the nurse so the area can be assessed and treatment started. On 5/2/23 at 2:39 PM, V14 (CNA) said that resident who are at risk for pressure ulcers or who have a pressure ulcer should be repositioned every hour or so. V14 said that she does not know how to adjust an air mattress. V14 said that whoever sets up the mattress, puts the settings to what they need to be at. V14 said that if a new reddened area is seen during a shower or cares, it should be reported to the nurse right away. On 5/2/23 at 11:41 AM, V3 said that she looked through R34's medical records and could not find any documentation that anyone was notified recently of R34's reddened spine. V3 said that it should have been reported to the nurse or herself right away so it could be assessed and treatment started. R34's Wound Care: Pressure Ulcer Form shows that she has a stage 2 pressure ulcer on her mid back with a date that it was noted as 5/2/23. R34's Physician's Orders for treatment of her spine pressure ulcer was dated 5/2/23. R34's Skin Integrity Care Plan shows that she has a history of pressure ulcers and interventions of: Mattress: Pressure reducing mattress in bed. Inspect my skin for any skin breakdown. Notify nurse, my POA (Power of Attorney) and my Dr. (Doctor) of any changes to my skin. Assist me with positioning while I am in my wheelchair and bed at regular intervals and as needed. The facility's Prevention of Pressure Ulcers/Injuries Policy revised 7/17 shows, Prevention: At least every hour, reposition residents who are chair-bound or bed bound with the head of the bed elevated 30 degrees or more. Select appropriate support surfaces based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors. Evaluate, report and document potential changes in in the skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145278 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 manage resident's pain for 1 of 18 residents (R8) reviewed for pain in the sample of 18. Residents Affected - Few The findings include: R8's facility assessment dated [DATE] show R8 has no cognitive impairment. R8's diagnoses include malignant neoplasm of uterus (cancer) fibromyalgia, osteoporosis, and respiratory failure. R8's physician order sheet (POS) dated 5/23 with and order date of 3/30/23 show R8 has an order of Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen/ Codeine) : Give 1 tablet by mouth every 8 hours as needed for pain 1-4 (mild pain) AND Give 2 tablet by mouth every 8 hours as needed for for pain level 5-10 (moderate to severe pain) On 5/1/23 at 9:15 am, R8 was in bed alert. R8 said the first weekend of April (April 8 Saturday, April 9 Sunday) her pain medication Tylenol with Codeine was not available. R8 said she went for 2-3 days without her pain medication. R8 said she has cancer and was in so much pain-my back was killing me R8 said she was repeatedly asking for pain medication, she was not able to sleep. R8 stated I was told my pain med's was not available. The next day it was the same. I did not get my pain medication until that Monday or Tuesday. On 5/2/23 at 10:51 am, V9 (License Practical Nurse-LP) said she is R8's regular nurse. V9 (LPN) said she was working that Saturday 4/8/23. V9 said R8 was complaining of pain and she was wanting her pain medication. R8's Tylenol with codeine was not available. V9 said she reordered to the pharmacy and waited. It did not come that day. The next day Sunday 4/9/23, V9 said she was again working and followed up from the pharmacy. R8 was in pain. V9 said she was told the pain medication needed a script. V9 said R8 was in severe pain and was really needing her Tylenol with codeine. R8's electronic medication administration on 4/8, 4/9 and 4/10/23 show R8 had a pain level of 5 and was supposed to get 2 tablets of Tylenol with codeine. The MAR was blank. V9 (LPN) confirmed that R8's pain medication was not given (unavailable) on 4/8, 4/9 and 4/10. (Saturday, Sunday, Monday) On 5/3/23 at 9 AM, V2 Director of Nursing (DON) said residents pain should be manage for their comfort. V2 (DON) said she had given inservices to the nurses that when a pain medication is not available, nurses should call the physician to get alternative pain medication. R8's careplan dated 3/30/23 show I am at risk for an alteration in comfort secondary to pain related to cancer, depression, fibromyalgia, osteoporosis with intervention to include, monitor pain each shift. Administer my medication as ordered by my MD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145278 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The facility policy entitled Pain Assessment and Management dated 3/2018 show, The purpose of this procedure are to help the staff identify pain in the resident, and to develop intervention consistent with the resident's goals and needs and that address the underlying causes of pain. 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Event ID: Facility ID: 145278 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review the facility failed to follow the menu during the noon meals. This failure has the potential to affect all 89 residents residing in the facility. Residents Affected - Many The findings include: The CMS-672 filled out and dated by the facility and dated 5/1/23 shows the total residents residing in the facility is 89. On 5/1/23 at 11:15 AM V7, Cook, was plating the lunch meal. A piece of plain white bread was included. On 5/1/23 at 11:42 AM, V7 said she follows the recipes to make the meals. On 5/1/23 at 11:32 AM V4, Dietary Manager, said they just switched to the summer/spring menu today. The facility's S/S (Spring/Summer) 2023 Menu Week 1 shows the Lunch meal on Monday, May 1 includes Parmesan Bread and shows the Lunch meal on Tuesday, May 2 includes Stuffing Crusted Pork Cutlet with Gravy. The facility's S/S 2023 Menu Week 1 Monday Lunch recipe for Parmesan Bread (undated) shows white bread slices are to be oiled with vegetable salad oil, sprinkles with parmesan cheese and broiled on one side and repeated on the other side. The facility's S/S 2023 Menu Week 1 recipe for Stuffing Crusted Pork Cutlet with Gravy (undated) shows prepared stuffing is supposed to be placed on top of each pork cutlet after the pork cutlet is seasoned and baked. The stuffing is to be spread evenly on the pork cutlet and baked until reaching 155 degrees F. A test meal tray for the lunch meal provided for sampling on 5/1/23 did not include Parmesan Bread. On 5/2/23 at 12:13 PM, a test meal tray for the lunch meal was received with a piece of pork with gravy over the top and stuffing on the side. On 5/1/23 at 11:05 AM, R38 said she wants to see the recipe book. R38 said she did not receive parmesan bread, it was white bread. R38 said we always just get white bread no matter what the menu says; it would have been a lot better if it had been parmesan bread. On 5/2/23 at 2:20 PM, V4, said it is important to follow the recipe to ensure that the residents receive the appropriate amount of nutrition and to make sure the correct seasonings are put in for the flavor. On 5/3/23 at 10:37 AM, V4 said Parmesan bread usually has the parmesan cheese on the bread and is toasted in the oven. V4 said baking the stuffing on the pork cutlet would change the texture of the stuffing by making it a little crispy. V4 said she has a meeting with the residents regarding their food preferences, but there are no meeting minutes taken. The facility's Resident Council meeting minutes for February 24th, 2023 shows the following: One resident wanted to donate parmesan cheese for the pasta dishes. Several residents agreed they would like to get parmesan more often. The facility's Menu & Nutritional Adequacy/Cycle Menu Policy (developed 4/2017) shows the facility will follow a weekly cycle menu planned at least one week in advance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145278 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure meals were prepared in a manner which is palatable for 5 of 18 residents (R49, R14, R38, R32, and R7) reviewed for food preferences in the sample of 18. Residents Affected - Many The findings include: On 5/1/23 at 10:05 AM, R7 said the food is like eating cardboard. It has no flavor and is either overcooked or undercooked. On 5/1/23 at 9:54 AM, R14 said the food has no flavor and they serve too much pasta. On 5/1/23 at 2:11 PM, R32 said she cannot eat the slop they call food here. R32 said it's either undercooked or overcooked and her daughter has to bring food for her to eat daily since the food tastes so badly. On 5/1/23 at 11:05 AM, R38 said the food tastes horrible and the pasta is mush. R38 said she did not receive parmesan bread, it was white bread and would have been a lot better if it had been parmesan bread. On 5/1/23 at 1:45 PM, R49 said the food has no taste and is burnt or overdone most of the time. During the kitchen inspection on 5/1/23 at 9:24 AM, the pasta for the lunch meal was already cooked and sitting in water on the steam table. On 5/1/23 at 11:15 AM, plating of the lunch meal was in progress and the pasta looked mushy. A plain piece of white bread was included. A test meal tray for the lunch meal was provided for sampling on 5/1/23 and again on 5/2/23. The pasta on 5/1/23 was mushy and the chicken cacciatore was bland tasting. No green peppers or onions were discernible in the chicken cacciatore. The noon meal on 5/1/23 did not include Parmesan Bread, but only a plain piece of white bread. The stuffing on 5/2/23 was mushy and served as a side dish to the gravy covered pork. The cooked cabbage on 5/2/23 was overly soft and bland. On 05/01/23 at 1:40 PM, V4, Dietary Manager, said plain tomato sauce, diced chicken, Italian seasoning, salt, pepper, garlic seasoning (not fresh garlic), fresh onion and canned red peppers were used to make the Chicken Cacciatore. On 5/1/23 at 2:20 PM, V4, Dietary Manager, said we put the food on the steam table around 9:45 AM since V6, Cook, goes to lunch around 10:00 AM. V4 said we keep other foods in the oven so they do not become mushy or have a change in the flavor before putting them on the steam table. V4, said it is important to follow the recipe to ensure that the residents receive the appropriate amount of nutrition and to make sure the correct seasonings are put in for the flavor. On 5/3/23 at 10:37 AM, V4 said Parmesan bread usually has the parmesan cheese on the bread and is toasted in the oven. V4 said baking the stuffing on the pork cutlet, as per the recipe, would change the texture of the stuffing by making it a little crispy. The facility's S/S (Spring/Summer) 2023 Menu Week 1 shows the Lunch meal on Monday, May 1 includes Chicken Cacciatore, Rotini Pasta, Italian Blend Vegetables, Mandarin and Parmesan Bread and shows the Lunch meal on Tuesday, May 2 includes Stuffing Crusted Pork Cutlet with Gravy, Buttered Cabbage, Cinnamon Applesauce, and Bread. The facility's S/S 2023 Menu Week 1 Monday Lunch recipe for Parmesan Bread (undated) shows white bread slices are to be oiled with vegetable salad oil, sprinkled with parmesan cheese and broiled on one side and repeated on the other side. The facility's S/S 2023 Menu Week 1 Monday Lunch recipe for Chicken Cacciatore shows the ingredients include vegetable salad oil, chopped onion, diced green pepper, chopped garlic, Italian seasoning, basil, oregano leaf, black (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145278 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete pepper, salt, granulated sugar, diced tomatoes, tomato sauce, and pulled/diced chicken (thawed). The facility's S/S 2023 Menu Week 1 recipe for Stuffing Crusted Pork Cutlet with Gravy (undated) shows prepared stuffing is supposed to be placed on top of each pork cutlet after the pork cutlet is seasoned and baked. The stuffing is to be spread evenly on the pork cutlet and baked until reaching 155 degrees F. The facility's Menu & Nutritional Adequacy/Resident Satisfaction Policy (developed 4/2017) shows the facility will serve foods that are palatable, attractive and at proper temperature to ensure resident satisfaction. Event ID: Facility ID: 145278 If continuation sheet Page 9 of 9