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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 145468 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 145468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Skokie, The 9615 North Knox Avenue Skokie, IL 60076 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)