Health inspection·April 17, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide care and services according to accepted standards of practice by failing to obtain a physician's order to remove an indwelling urinary catheter for a resident diagnosed with urinary retention and failed to review a resident's hospital records upon admission for the diagnosis and follow up care for an indwelling urinary catheter. These failures affected one (R1) of four residents reviewed for improper nursing care. Residents Affected - Few Findings include: R1 is [AGE] years of age. Current diagnoses include but are not limited to Persistent Atrial Fibrillation, Influenza A, Dementia, Myocardial Infarction, Hypertension on admission 3/31/25 and Elevated [NAME] Blood Cell Count on 4/3/25. R1's comprehensive assessment section C cognitive status dated 4/7/2025 documents a brief interview for mental status score of 3/15. This score indicates R1 has severe cognitive impairment. During observations in the facility on 4/15/25, R1 was not in the facility during the investigation. R1 was admitted to the hospital on [DATE] due to abnormal lab results for BUN (Blood Urea Nitrogen) and UTI (urinary tract infection). On 4/15/25 at 11:24 AM, V4 Licensed Practical Nurse (LPN) was inquired of R1's care. V4 said, when I took care of him, he didn't have a urinary catheter. On 4/16/25 at 10:17 AM, V2 Director of Nursing (DON) was inquired of V7 Assistant Director of Nursing (ADON) for interview regarding R1's 4/1/25 progress note on removing his urinary catheter. V2 said, V7 is the ADON, she's out of the country on vacation right now. On 4/16/25 at 12:05 PM, V2 was inquired of R1's hospital discharge instructions related to the urinary catheter and V7 removing R1's urinary catheter on 4/1/25. V8 RN Registered Nurse took R1's admission report from the hospital. I see she put he had urinary retention with a foley (indwelling) catheter. I missed the page on the transition of care document. R1 had a foley catheter because of his urinary retention. Based on his diagnosis and clinical document his catheter was not to be removed. I reviewed the POS (physician order sheets) and there was no order from the doctor to discontinue the catheter. It requires to have a physician order to discontinue it. There was a medical diagnosis, we should have reviewed his hospital documents thoroughly. We should have got an order from the doctor or NP (nurse practitioner) before discontinuing the catheter. R1's medical records were reviewed. On 3/31/25 at 7:35 PM, R1 was admitted to the facility with a Page 1 of 6 145468 145468 04/17/2025 Citadel of Skokie, The 9615 North Knox Avenue Skokie, IL 60076

F 0658 urinary catheter in place from the hospital. Level of Harm - Minimal harm or potential for actual harm On 4/1/25 at 1:15 PM, V7 ADON's progress note documents the following: Resident foley catheter discontinued for no qualifying diagnosis. R1's physician orders from 3/31/25 to 4/10/25 do not document an order to remove his urinary catheter. Residents Affected - Few Review of V8 RN's 3/31/25 hospital admission report documents a significant medical history of urinary retention with foley catheter 16 F (French) in place. R1's discharge instructions reason for hospital stay state in part: you had urinary retention, and a catheter was placed. You should follow up with Urology as an outpatient. You were started on Doxazosin to treat enlarged prostate. Your next steps- schedule an appointment with V9 Urology MD (Medical Doctor) as soon as possible for a visit in one week for hospital follow up and management of urinary retention. Active drain: urinary catheter placement date 3/20/25. Reason for foley catheter maintenance: acute urinary retention: bladder outlet obstruction, or neurogenic bladder. V9 MD's consultant recommendation documents- would recommend discharge home with foley (indwelling) catheter. Would recommend follow up with urology. Patient may need to have chronic foley (indwelling) catheter versus surgical insertion of suprapubic tube. Detailed hospitalization summary states in part: Urinary Retention foley catheter placed 3/20 and adjusted based on 3/29 CT (computed tomography) scan. Started doxazosin (as it can be crushed). Urology consulted: plan to discharge with foley catheter and will need outpatient follow up with urology V9 MD or colleague. V2 DON confirmed R1 was not seen by V9 MD as ordered 1 week after being discharged from the hospital. There is no documentation the facility notified V9 MD that R1's urinary catheter was removed by V7 ADON on 4/1/25. The facility failed to document R1's urinary retention from his transition of care forms dated 3/31/25. V7 ADON failed to review R1's 3/31/25 hospital discharge forms and transition of care forms that document R1's urinary retention and treatment with the urinary catheter prior to removing his catheter. V7 did not obtain a physician's order to discontinue R1's urinary catheter. During course of survey, the facility failed to provide requested facility policies. 145468 Page 2 of 6 145468 04/17/2025 Citadel of Skokie, The 9615 North Knox Avenue Skokie, IL 60076

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a physician's order to remove an indwelling urinary catheter for a resident diagnosed with urinary retention and failed to review a resident's hospital records upon admission for the diagnosis and follow up care for the indwelling urinary catheter. These failures affected one (R1) of four residents reviewed for improper nursing care. This failure resulted in R1 developing abnormal lab values with urinary retention and UTI (Urinary Tract Infection), subsequently requiring hospitalization. Findings include: R1 is [AGE] years of age. Current diagnoses include but are not limited to Persistent Atrial Fibrillation, Influenza A, Dementia, Myocardial Infarction, Hypertension on admission 3/31/25 and Elevated [NAME] Blood Cell Count on 4/3/25. R1's comprehensive assessment section C cognitive status dated 4/7/2025 documents a brief interview for mental status score of 3/15. This score indicates R1 has severe cognitive impairment. During observations in the facility on 4/15/25, R1 was not in the facility during the investigation. R1 was admitted to the hospital per review of the facility census and electronic medical record on 4/10/25 due to abnormal lab results for BUN (Blood Urea Nitrogen) 99 mg/dl (milligrams/deciliter). This is significantly elevated and considered a serious indicator of kidney dysfunction or other health issues. The normal range for the BUN is 7-20 mg/dl. R1 was admitted for a UTI (urinary tract infection). On 4/15/25 at 11:24 AM, V4 Licensed Practical Nurse (LPN) was inquired of R1's care. V4 said, R1 had some abnormal labs. When I took care of him, he didn't have a urinary catheter. His BUN was high 99. He was already on an antibiotic for Leukocytosis (elevated white blood cell count). He was on Amoxicillin then the Nurse Practitioner (NP) switched it to Cipro. On April 3rd his admission labs included a UA (urinalysis) and C&S (culture and sensitivity) due to abnormalities as a prophylactic. He was transferred to the hospital on April 10th, it was due to his Leukocytosis. Haven't heard anything yet from the hospital. On 4/16/25 at 10:17 AM, V2 Director of Nursing (DON) was inquired of V7 Assistant Director of Nursing (ADON) for interview regarding R1's 4/1/25 progress note on removing his urinary catheter. V2 said, V7 is the ADON, she's out of the country on vacation right now. On 4/16/25 at 12:05 PM, V2 DON was inquired of R1's hospital discharge instructions related to the urinary catheter and V7 ADON removing R1's urinary catheter on 4/1/25. V2 said, R1 was to follow up with urology in a week. Our receptionist schedules all the appointments. She's not a nurse. The receptionist scheduled him to see urology on May 12th at 9:40 AM. I'd have to find out with her why it was for that date. I gave her the hospital follow up instructions to set up the appointment with urology. V7 ADON and I follow up with the appointments. The receptionist sends us an email when she makes the appointments, and we discuss it in our morning meetings. I wasn't able to check on this or the urgency of his appointment. V2 DON said, I reviewed the transition of care documents, and I wasn't able to locate a diagnosis 145468 Page 3 of 6 145468 04/17/2025 Citadel of Skokie, The 9615 North Knox Avenue Skokie, IL 60076

F 0690 Level of Harm - Actual harm Residents Affected - Few for the catheter. V8 RN Registered Nurse took R1's admission report from the hospital. I see she put he had urinary retention with a foley (indwelling) catheter. I missed the page on the transition of care document. R1 was on a foley catheter because of his urinary retention. Based on his diagnosis and clinical document his catheter was not to be removed. I reviewed the POS (physician order sheets) and there was no order from the doctor to discontinue the catheter. It requires to have a physician order to discontinue it. There was a medical diagnosis, we should have reviewed his hospital documents thoroughly. We should have got an order from the doctor or NP (nurse practitioner) before discontinuing the catheter. R1's medical records were reviewed. On 3/31/25 at 7:35 PM, R1 was admitted to the facility with a urinary catheter in place from the hospital. On 4/1/25 at 11:47 AM, R1 was seen by the internal medicine nurse practitioner in the facility. The nurse practitioner did not document R1's urinary catheter during her assessment. The documentation states in part- Urinary: no dysuria (painful urination), hematuria (blood in urine). Reviewed: labs/hospital records/chart/ allergies/meds/MD (medical doctor) and nursing notes. On 4/1/25 at 1:15 PM, V7 ADON's progress note documents the following: Resident foley catheter discontinued for no qualifying diagnosis. R1's physician orders from 3/31/25 to 4/10/25 do not document an order to remove his urinary catheter. Review of V8 RN's 3/31/25 hospital admission report documents a significant medical history of urinary retention with foley catheter 16 F (French) in place. R1's discharge instructions reason for hospital stay state in part: you had urinary retention, and a catheter was placed. You should follow up with Urology as an outpatient. You were started on Doxazosin to treat enlarged prostate. Your next steps- schedule an appointment with V9 Urology Medical Doctor (MD) as soon as possible for a visit in one week for hospital follow up and management of urinary retention. Review of R1's physician order sheets documents Doxazosin Mesylate 1 tablet by mouth one time a day for HTN ordered 3/31/25. The medication can be used to treat urinary problems caused by an enlarged prostate. It can also treat high blood pressure when used alone or in combination with other medications. R1's transition of care form dated 3/31/25 documents contact information for follow up providers. V9 MD is listed to schedule an appointment as soon as possible for a visit in one week for hospital follow up and management of urinary retention. V9's address and phone number are listed. Active drain: urinary catheter placement date 3/20/25. Reason for foley catheter maintenance: acute urinary retention: bladder outlet obstruction, or neurogenic bladder. V9 MD's consultant recommendation documents- would recommend discharge home with foley (indwelling) catheter. Would recommend follow up with urology. Patient may need to have chronic foley (indwelling) catheter versus surgical insertion of suprapubic tube. He has multiple medical problems and may not benefit from transurethral resection of bladder outlet obstruction. Detailed hospitalization summary states in part: Urinary Retention foley catheter placed 3/20 and 145468 Page 4 of 6 145468 04/17/2025 Citadel of Skokie, The 9615 North Knox Avenue Skokie, IL 60076

F 0690 Level of Harm - Actual harm Residents Affected - Few adjusted based on 3/29 CT (computed tomography) scan. Started doxazosin (as it can be crushed). Urology consulted: plan to discharge with foley catheter and will need outpatient follow up with urology V9 MD or colleague. V2 DON confirmed R1 was not seen by V9 MD as ordered 1 week after being discharged from the hospital. There is no documentation the facility notified V9 MD that R1's urinary catheter was removed by V7 ADON on 4/1/25. On 4/3/25 at 1:32 PM, R1's nurse practitioner ordered a stat (immediate) urine analysis and culture/sensitivity. On 4/4/25 at 8:49 PM, R1's urine test results document- antimicrobial resistance and urinary bacteria. R1's nurse practitioner was informed with no new orders received. The laboratory report documents urinary bacteria- Pseudomonas Aeruginosa and Citrobacter Freundii. On 4/7/2025 at 11:39 AM, R1 was assessed by his nurse practitioner regarding the urine test results. The nurse practitioner documents the following- Internal Medicine Progress Note CC/ reason for visit: UTI/leukocytosis Assessment and Plan: #. UTI: - UA/CS with Pseudomonas aeruginosa and Citrobacter Freundii. To start Cipro 500mg BID x 5 days. On 4/10/25 R1 was transferred to the hospital via ambulance for abnormal lab results. R1's 4/10/25 emergency room provider notes state in part: HPI History of present illness- R1 presents with abnormal labs. According to paperwork he had blood drawn today and revealed that his creatinine increased from 4 to 1 from last week. Patient currently being treated for urinary tract infection with Ciprofloxacin which he started a few days ago. Medical decision making: R1 presents with a urinary tract infection, questionable altered mental status as well as increased creatinine on outpatient labs. We did perform a bladder scan which revealed 1400 ml (milliliters) of purulent (containing or producing pus, a thick yellowish fluid that indicates infection) urine in the patient's bladder. This was removed with a foley catheter however appeared to be similar to frank pus. (Clear and evident presence of pus, a thick, usually yellow or greenish fluid, in a wound or other area of the body. It's a sign that the area is infected, indicating the body's immune system is actively fighting an infection.) R1 remains hospitalized at this time. R1's nephrology consult note, during hospitalization dated 4/12/25 documents, HPI: presented from his Nursing Home for increase in his Creatinine levels from a week ago. During recent hospitalization 3/12 3/21 for lethargy secondary to sepsis to influenza and aspiration pneumonia, course was complicated by Acute Kidney Injury and urinary retention, where a foley was placed. Urology recommending discharge home with Foley Catheter, follow- up with urology, and chronic Foley versus surgical insertion of suprapubic tube. UA (urinalysis) was unable to be completed due to purulent urine, though it did show extensive neutrophils and bacteria, foley catheter is in place, but the bladder was distended on CT, also with new bolateral (sic) hydronephrosis. On 4/17/25 at 8:25 AM, call placed to V9 MD's office for interview. Message left with staff, awaiting return call. On 4/17/25 at 11:31 AM, received a return call from V9 MD's office that V9 is in surgery and another staff will attempt to return the call. 145468 Page 5 of 6 145468 04/17/2025 Citadel of Skokie, The 9615 North Knox Avenue Skokie, IL 60076

F 0690 During course of survey, facility failed to provide requested policies. Level of Harm - Actual harm National Institute of Health (December 2019) documents (in part) Urinary retention is a condition in which you cannot empty all the urine from your bladder. Urinary retention can be acute-a sudden inability to urinate, or chronic-a gradual inability to completely empty the bladder of urine. Urinary retention results from either a blockage that partially or fully prevents Treatments for urinary retention may include draining the bladder Residents Affected - Few Administrative Code TITLE 68: Professions And Occupations (January 4, 2021) Professional Responsibility includes making decisions and judgments requiring use of knowledge acquired by completion of an approved program for licensure as a practical, professional or advanced practice registered nurse. 145468 Page 6 of 6