Health inspection·June 12, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review the facility failed to ensure residents were treated in a dignified manner. This applies to 4 of 18 residents (R68, R64, R51, R66) reviewed for dignity in the sample of 18. The findings include: 1. On June 11, 2024 at the noon meal, all the residents in the dining room were served their meals. R68 was sitting in her reclining wheelchair. R68's meal was sitting in front of her. No one was helping R68 to eat. The other residents at R68's table were being fed as well as the rest of the dining room could feed themselves. R68 was the only one not eating. 2. On June 11, 2024 at the noon meal, V10 Memory Care Director was standing up while feeding R64 and R51. The facility's quality of life - dignity policy dated February 2020 shows, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling or self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times. 3. On 6/10/2024 at 12:00 PM, V4 Certified Nursing Assistant (CNA) said we normally get feeders first when asked about resident room trays being delivered while she was standing right outside of R66's room doorway. V4 was observed bringing a tray into R66's room who required feeding assistance. On 6/11/2024 at 2:04 PM, V2 Director of Nursing (DON) said staff should not refer to residents as feeders because it's a dignity issue. The facility's Quality of Life - Dignity policy reviewed 2/2020 states . Residents are treated with dignity and respect at all times. staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs . Page 1 of 7 145278 145278 06/12/2024 Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who requires extensive assistance was assisted with washing her hands after having a bowel movement. This applies to 1 of 18 residents (R64) reviewed for Activities of Daily Living (ADLs) in the sample of 18. Residents Affected - Few The findings include: On June 10, 2024 at 11:28 AM, V7 and V8, both Certified Nursing Assistants (CNAs) were getting R64 out of bed for lunch. R64 had her right hand reaching towards her buttock. R64 had a bowel movement. R64 had stool on her right hand and leg like she had placed her hand in the stool. V7 and V8 CNAs cleaned R64's hands with a washcloth but did not get all of the stool out from under her fingernails or use soap. They put R64 in her wheelchair and took her to lunch without washing her hands. R64 had a brown/black like substance under her fingernails and around her nail bed. On June 11, 2024 at 9:18 AM, R64 was sitting up in her wheelchair in the dining room. R64's right hand still had a brown/black substance under her fingernails. R64 was scratching her face and head with her right hand. R64's Minimum Data Set, dated [DATE] shows, she is not cognitively intact and is dependent on staff for personal hygiene and toileting hygiene. R64's care plan dated June 3, 2024 shows, I have decreased eating skills, will eat some food with my fingers . R64's care plan does not address her dependence on staff for ADL's. The facility's activities of daily living (ADLs), supporting dated March 2018 shows, Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 145278 Page 2 of 7 145278 06/12/2024 Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081

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 ensure treatments were in place for residents with pressure injuries. This applies to 2 of 4 residents (R68 and R64) reviewed for pressure injuries in the sample of 18. Residents Affected - Few The findings include: 1. R68's wound assessment dated [DATE] shows, she has a facility acquired stage 4 sacral wound measuring 0.8 cm (centimeters) X 0.3 cm X 0.2 cm (length X width X depth). On June 10, 2024 at 11:19 AM, R68 was lying in bed. V7 and V8 both Certified Nursing Assistants (CNAs) were getting R68 out of bed for lunch. R68 had a loose dressing on her coccyx dated June 8, 2024. Two of the four sides were not sticking to her coccyx. V7 CNA pulled back the dressing and showed this surveyor R68's wound. There was an approximately nickel size open wound. The center of the wound appeared black. There was some drainage on the dressing. V7 CNA tried to stick the dressing back on and continued getting her up. On June 11, 2024 at 11:46 AM, V9 Licensed Practical Nurse (LPN) stated, V9 was the nurse taking care of R68 on June 10, 2024. V9 said V9 checks all the dressings and makes sure they are intact, but she did not change R68's dressing on June 10, 2024 and no one reported anything to her about R68's dressing. On June 12, 2024 at 9:29 AM, V3 Wound Care Nurse stated, the nurses should be checking all the wounds and changing the dressings as the physician order says or when it is needed. R68's treatment administration record (TAR) for June 2024 shows, Sacrum: cleanse wound with Dakin's solution (house stock) pack wound bed with xeroform gauze. Skin prep to peri-wound and cover with foam with border as needed for loose or soiled dressing. The TAR shows, the dressing was changed at 9:48 PM on June 10, 2024 (10 hours later). R68's care plan dated January 18, 2024 shows, Focus: I have pressure injury to my sacrum related to decreased mobility, incontinence, poor appetite, end of life receiving hospice. Wound MD (medical doctor) will be managing wounds . Interventions: Treatments per wound care MD . Administer treatments as ordered and monitor for effectiveness. 2. R64's wound assessment details dated June 4, 2024 shows, she had a stage 3 wound to her coccyx. On June 10, 2024 at 11:28 AM, R64 had red open areas on her coccyx (like a rash). There was no dressing on her coccyx. On June 11, 2024 at 9:29 AM, R64 had red open areas on her coccyx (like a rash) and an open area in the slit of her buttock approximately the size of a dime. There was no dressing on her coccyx. R64's current medication review report shows, cleanse coccyx with wound cleanser and pat dry. Apply skin prep to peri wound and allow to dry. Apply hydrocolloid (wound dressing) . On June 12, 2024 at 9:29 AM, V3 Wound Care Nurse stated, she did R64 admitting assessment. R64 had 145278 Page 3 of 7 145278 06/12/2024 Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a stage 2 or 3 on her coccyx. There should be an order to monitor every shift and make sure the dressing is intact. They are supposed to change it [the dressing]. If there isn't a dressing in place, then the nurses should be putting one on. R64's care plan dated May 29, 2024 shows, Focus: I am at risk for impaired skin integrity related to advanced age, decreased mobility, dementia. I have a stage 3 pressure ulcer on coccyx on admission to facility, chronic scratching, unable to make needs known . Interventions: monitor dressing during peri care as patient often removes or becomes dislodged with inc (incontinence) stool. The facility's pressure ulcer treatment policy dated November 2013 shows, Purpose: The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. General Guidelines: 1. The pressure ulcer treatment program should focus on the following strategies: .c. pressure ulcer care. 145278 Page 4 of 7 145278 06/12/2024 Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm 2. R339's face sheet lists his diagnoses to include: chronic obstructive pulmonary disease, chronic respiratory failure, dysphagia, unilateral inguinal hernia, congestive heart failure, alcohol dependence disorder, dementia, and alcohol abuse. Residents Affected - Few On June 11, 2024 at 9:45 AM, R339 was awake lying in bed. R339 was very thin and stated, he has lost weight. R339 was not sure why and that he just wasn't hungry. R339's weights and vitals summary shows, his weight on May 6, 2024 was 113.6 lbs. (pounds) and was 99.4 lbs. on May 20, 2024 (14 lbs. weight loss, 12.50%, 14 days later). R339's electronic medical records shows, the last time he was seen by the dietitian was on April 28, 2024. The progress note shows, RD [registered dietitian] WT [weight] REVIEW/WEIGHT WARNING: Value: 110.4#, BMI [body mass index] 20 low for age. sig [significant] wt. loss x 1 month noted. Overall weight is now slightly more stable x 2 weeks . REVIEW: res [resident] recently downgraded diet to mech soft [mechanical soft] for pocketing/chewing difficulty. He does have CHF [congestive heart failure] and some fluid shifts likely causing weight loss/gain. REC: add house supplement/ensure BID [twice daily] for supplement and weekly weights- monitor on NAR [nutrition risk assessment]. R339's electronic medical record shows, he has not been weighed weekly. The last weight record was May 20, 2024. R339's electronic medical record does not show, an order for weekly weights. R339's progress notes dated May 20, 2024 shows, Call placed to son/POA [power of attorney] to inform of weight loss and poor appetite. Message left to call facility. Referral to dietician. MD [medical doctor] updated. R339's electronic medical record does not show any new orders or interventions in place following his 14 lbs. 12.50% weight loss in 14 days. On June 11, 2024 at 11:22 AM, V6 Dietitian stated, she was aware of R339's weight loss. V6 said she asked the facility for a re-weigh to ensure the May 20, 2024 weight was correct. V6 said she has not put any interventions in place because he hasn't been re-weighed. V6 said the facility should be following her recommendations of weekly weights. Based on observation, interview, and record review the facility failed to ensure there was no delay in notifying a dietitian of severe weight loss in residents and failed to ensure there was no delay in implementing the dietitian's recommendations for residents with severe weight loss. This failure resulted in the delayed treatment and monitoring of residents with severe weight loss. This applies to 3 of 3 residents (R27, R339, R61) reviewed for severe weight loss in the sample of 18. The findings include: 1. R27's Weights and Vitals Summary report showed on 9/5/23 R27 weighed 127.5 pounds and on 10/4/23 weighed 112.4 pounds. A severe weight loss of 13.4% in one month. R27's Progress Note dated 10/12/23 showed the dietitian recommended R27 to receive a dietary 145278 Page 5 of 7 145278 06/12/2024 Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081

F 0692 supplement twice a day. Level of Harm - Actual harm R27's Progress Notes dated 10/16/23 showed the doctor was notified of the dietitian's recommendations. Residents Affected - Few A fax to R27's physician dated 10/18/23 showed the physician was notified for a second time of the dietitian's recommendation made on 10/12/23 for R27 to receive a dietary supplement twice a day. R27's Progress Notes dated 10/18/23 showed the doctor agreed with the dietitian's recommendation. R27's Physician Order Summary showed the dietitian's recommendation for the supplement was started on 10/19/23 (15 days after R27's weight lost was identified). On 6/11/24 at 11:00 AM, V6 (Dietitian) said she would expect to be notified of a resident's significant/severe weight loss as soon as possible so the resident can be evaluated, and interventions started if needed. V6 said the process can take up to one week. V6 said in October 2023, she was transitioning into the role as the facility's dietitian and was not sure why there was a delay in addressing R27's weight loss. V6 add that a significant/severe weight loss is considered a change in the resident's condition. On 06/11/24 at 1:25 PM, V5 (Dietary Manager) said the normal time frame for notifying the dietitian of a significant weight loss and the implementation of the dietitian's recommendation is no longer than a week. V5 said she was not sure why there was a delay in addressing R27's weight loss as she was new to the role of dietary manager in October 2023. R27's Care Plan showed R27 was at risk for unplanned weight loss. 3. R61's Weights and Vitals Summary report showed on 5/6/24 R61 weighed 168.5 pounds and on 6/2/24 weighed 159.4 pounds. A severe weight loss of 5.4% in one month. On 6/11/2024 at 11:10 AM, V6 (dietitian) said she recommended weekly weighs for [R61] because he was being monitored for weight loss following a hospitalization. R61's Progress Notes entered on 5/21/2024 by V6 states, continue on weekly weights and monitor via NAR. R61's Weights and Vitals Summary dated 6/11/2024 shows a weight of 159.4 lbs. on 6/2/2024 with no additional weight listed to current (6/11/2024). R61's Care Plan dated 5/16/2024 states, Weigh me as ordered and notify my nurse, my physician, the dietary manager, and the dietitian of any significant weight loss. On 6/11/2024 at 2:04 PM, V2 Director of Nursing (DON) said the dietitian's frequency of weight recommendations should be followed for residents. The facility's weight change assessment and intervention dated September 2018 shows, Policy Statement: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy interpretation and implementation: Weight assessment: 2. Weights will be recorded in the individual's medical record. 3. Any weight change of 5% or more since the last 145278 Page 6 of 7 145278 06/12/2024 Citadel of Sterling,the 105 East 23rd Street Sterling, IL 61081

F 0692 weight assessment, If the weight is verified, nursing will notify the Dietitian and MD/NP (medical doctor/nurse practitioner). Level of Harm - Actual harm Residents Affected - Few 145278 Page 7 of 7