Health inspection·August 7, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and notify the wound care physician with changes in a pressure injury, and failed to implement pressure relieving intervention to prevent a pressure injury. This applies to 2 of 8 residents (R95 & R100) reviewed for pressure injuries in the sample of 23. These failures resulted in R100's pressure injury deteriorating to an unstageable pressure injury. Residents Affected - Few The findings include: 1. R100's face sheet lists his diagnoses to include: nondisplaced intertrochanter fracture (hip fracture), type I diabetes mellitus, and coronary heart disease. R100's wound assessment report, dated 7/3/24 shows a newly identified stage 1 pressure ulcer was found on his right heel. The pressure ulcer measured 7.00 cm (centimeters) X 5.00 cm. R100's care plan, with problem onset of 7/10/24, shows, Problem/Need: Pressure ulcer stage 2 to right bottom heel. Approaches: Measure wound at least weekly. Record HxWxL (height x width x length), appearance, amount and odor of any drainage. Report any decline in would status to physician. R100's local hospital vascular surgery progress notes, dated 7/22/24 show, This is a [AGE] year-old gentleman who has a history of insulin dependent diabetes. Most recent A1C (blood check for insulin) from April of 2024 A1C 7.7. He has been following with podiatry for tissue loss. He unfortunately had a left hip fracture and was admitted to rehab From the standpoint of his lower extremity vasculature he has normal toe pressures bilaterally. On the left his ABI (ankle brachial index) is likely falsely elevated secondary to medical calcinosis with the waveform morphology demonstrates small T-wave phasic waveform. On physical exam he has clearly audible posterior tibial signal. From the standpoint of his lower extremity aterial perfusion I do believe with his toe pressure within normal limits he has enough perfusion to heal this superficial wound to the posterior heel We would recommend continued local wound care either with the podiatry clinic or with the wound care center. R100's wound assessment report dated 7/30/24 shows the same pressure ulcer was now a stage 2 measuring 3.00 cm X 3.00 cm with 5% slough and 95% granulation. Stage 2 pressure ulcer to bottom of right heel/foot assessed. Wound continues improving . On 8/7/24 at 9:05 AM, V4, Wound Care Nurse (WCN), stated R100 had a pressure ulcer on his heel that was healing. She sees him weekly to do assessments, otherwise, the floor nurses do the dressing changes daily. R100 had gone to a vascular appointment on 7/22/24 that was previously scheduled prior to admit to the facility. At that appointment, they did a doppler to check the pressures in his legs. Page 1 of 11 145563 145563 08/07/2024 The Citadel at Saint Anne Place 4405 Highcrest Road Rockford, IL 61107

F 0686 They did not find anything significant and referred him to a wound care doctor to follow for his pressure ulcer. She stated he has not seen any wound care doctors yet and does not have any appointments set up. Level of Harm - Actual harm Residents Affected - Few On 8/7/24 at 10:00 AM, R100 was lying in bed. He had a quarter size black soft circular wound to his right heel. He winced in pain when V4, WCN (Wound Care Nurse), removed the dressing and pressed in the middle of the wound. He stated the wound hurt and was painful. At 10:40 AM, V4, WCN, stated, The wound has deteriorated in one week since I last saw it. Now it has eschar (dead tissue). I would expect the floor nurses to notify me and the doctor of any changes in the wound. She had not heard anything about any changes in the wound. On 8/7/24 at 10:35 AM, V11, Wound Care Doctor, stated, If the wound is soft (boggy) as being described, I would call it an unstageable necrosis. I would expect the facility to manage a stage 1 or 2 pressure injury, but beyond that they should be consulting with someone with experience (him or an outside wound care clinic). The facility's Procedure: Pressure injury assessment/treatment, dated July 2024, shows, Purpose: The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified pressure injuries, alterations in skin integrity, and the prevention of acquiring additional pressure injuries Definitions and descriptions: B. Pressure injury: A localized injury to the skin and/or underlying tissues as a result of pressure or pressure in combination with shear/friction. Pressure injuries usually occur over a bony prominence and are staged to classify the degree of damage. I. Eschar tissue: Dead or devitalized tissue that is hard or soft in texture; usually black, brown or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound Stage 2 Pressure injury: Partial-thickness loss of skin with exposed dermis. The wound bed is pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible, Granulation tissue, slough and eschar are not present Unstageable: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (yellow, tan, gray, green or brown) or eschar (tan, brown or black) in the wound bed. 2. R95's Physician Orders Summary for August 2024 shows an order, with a start date of 1/23/24, for oxygen at 2-4 liters continuous, and an order with a start date of 2/24/24, for (ear protectors) applied to oxygen tubing at all times. R95's current Care Plan shows he has a self care deficit and requires extensive staff assistance for his Activities of Daily Living due to weakness. The Care Plan also shows on 7/17/24 he was found to have stage 2 pressure ulcer behind his right ear. A Wound Assessment Report completed on 7/17/24 shows R95 has a new facility acquired stage 2 pressure ulcer measuring .30 cm long, X .30 cm wide, X .20 cm deep with a scant (small) amount of serous (clear) drainage. A Braden Risk Assessment reported, completed 7/17/24, shows R95 is at high risk to develop a pressure injury. On 8/5/24, at 10:30 AM, R95 was lying in bed with his wife at his bedside. R95 had oxygen running via a nasal cannula tubing which was behind both ears. Behind and under his right ear were some gauze 145563 Page 2 of 11 145563 08/07/2024 The Citadel at Saint Anne Place 4405 Highcrest Road Rockford, IL 61107

F 0686 bandages, and behind his left ear wrapped around the tubing was a Styrofoam circular tube. Level of Harm - Actual harm On 8/6/24 at 11:42 AM, V7 (R95's spouse) said, He (R95) has been on oxygen continuously since he has been at the facility and he has a sore behind his ear from the oxygen tubing. The grips they use on the tubing are useless, they slide around all the time and fall off when staff reposition him. I come to the facility every day and sometimes the grips are just lying on his bedside table and not even on the tubing. Residents Affected - Few On 8/6/24 at 1:02 PM, V4 (Wound nurse) said the oxygen tubing around R95's ear caused a stage 2 pressure injury. V4 said they use (ear protectors-- grips like a foam pool noodle) to try to prevent it, but they are not effective they don't stay in place and they pop off the tubing from him moving. On 8/7/24 at 9:16 AM, V6 (Regsitered Nurse/RN) said R95's tube grips fall off and slide around. He said he is unaware of any other interventions that were tried to prevent the pressure injury. V6 said the staff do not do daily checks behind the ears of residents on oxygen; they check when a resident is bathed, or once a week on skin check days and oxygen tubing change days. The facility provided Pressure Injury Assessment/Treatment policy, revised 7/2024, shows pressure relieving devices should be observed for effectiveness and interventions changed or implemented to prevent the development of pressure injuries. 145563 Page 3 of 11 145563 08/07/2024 The Citadel at Saint Anne Place 4405 Highcrest Road Rockford, IL 61107

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R4's care plan problem, onset dated 11/3/23, shows, (R4_ has a history of falling. Approaches: 6/12/24 ** Low/peddle reclining chair to decrease risk of falling and sustaining an injury. R4's all facility patient communication tool, dated 6/12/24, shows, Pt (patient) fell out of reclining wheelchair . The IDT (interdisplinary team) follow up/review/summary/root cause determination, dated 6/13/24, shows, (R4) sustained a fall from her chair on 6/12/24 at 1845 (6:45 PM), (R4) tends to get anxious and has been observed being fidgety in her chair Intervention put in place, low/peddle reclining chair to decrease her risk of falling and risk for injury. On 8/5/24 at 10:14 AM, R4 was sitting up in a high reclining wheelchair. She was slightly restless and was trying to remove the blanket on her lap and pillow behind her head. There was another resident's name on the back of the wheelchair. On 8/6/24 at 9:44 AM, R4 was sitting up in a different lower reclining wheelchair. On 8/6/24 at 2:26 PM, V9, Restorative Nurse, stated, (R4) has high anxiety and moves around a lot in her wheelchair. She was previously in a higher reclining wheelchair, but then had a fall out of it, and the intervention put in place was a lower reclining wheelchair. She stated she didn't know why she was in a different wheelchair. (R4_ should only be in the low peddled reclining wheelchair. The facility's fall policy, dated July 2023, shows, The purpose of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall The falls should be reviewed at the daily stand-up meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls. Based on observation, interview, and record review, the failed to ensure a resident at risk for falls was supervised during toileting, and failed to implement fall prevention interventions for a resident at high risk of falls for 2 of 6 residents (R114, R4) reviewed for safety/supervision in the sample of 23. The findings include: 1. R114's face sheet shows she was admitted to the facility on [DATE] after she had a fall at home, resulting in a humerus fracture. R114's current Care Plan shows she is at risk for falls and has impaired mobility with transfers and ambulation and requires staff assistance with her Activities of Daily Living (ADL's). A facility provided Incident Report shows R114 had a fall on 4/21/24 out of her chair while trying to reach a napkin. A second Incident Report, dated 5/11/24, shows R114 had another fall from the toilet in the bathroom. The incident report shows, CNA (Certified Nursing Assistant) education given to not leave resident in the bathroom. The report also shows R114 sustained a 3 cm (centimeter) x 2.5 cm skin tear to her right upper arm, steri-strips were applied and she was sent to a local emergency room (ER) for evaluation. 145563 Page 4 of 11 145563 08/07/2024 The Citadel at Saint Anne Place 4405 Highcrest Road Rockford, IL 61107

F 0689 Level of Harm - Minimal harm or potential for actual harm A nursing note completed on 5/11/24 at 5:01 PM shows at 9:50 AM, R114 was found on the floor of her bathroom. R114 stated to staff she was trying to get off the toilet, I couldn't reach the call light. The nursing note also shows that blood was running down her arm from a skin tear and R114 said she hit her head on the shower edge. R114 was transferred to a local ER due to being on a blood thinner and having hit her head. Residents Affected - Few A Post Fall Assessment completed by V9 (Restorative Nurse) shows this resident was on the falling star program and should not have been left alone in the bathroom. On 8/6/24 at 12:22 PM, V9 said R114 was at risk for falls and is on the falling star program (residents at risk for falls) so she should not have been left alone in the bathroom. On 8/7/24 at 9:27 AM, V8 (CNA) said she was the CNA who left R114 in the bathroom the day of her fall. V8 said it was a busy morning, and she had never toileted R114 before, but she seemed with it enough to leave her unsupervised while she used the toilet. V8 said the call light was behind R114 and she was not able to reach it, and she should not have left her alone in the bathroom. The facility provided Falls Prevention policy, revised on 7/2023, shows the facility should provide residents an environment that is free from accidents and provide supervision and interventions to prevent avoidable accidents. The facility provided Answering the Call Light policy, last revised on 12/2017, shows call lights should be within reach of residents. 145563 Page 5 of 11 145563 08/07/2024 The Citadel at Saint Anne Place 4405 Highcrest Road Rockford, IL 61107

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a medication as ordered for one of 23 residents reviewed for medications in the sample of 23. The findings include: R33's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses including osteoarthritis, repeated falls, and anxiety disorder. R33's Physician Orders dated August 2024, shows an order for lidocaine 5% patch apply one patch to lower back in the am and off at bedtime. On 8/6/24 at 8:35 AM, V3, RN (Registered Nurse), was giving R33 his morning medications. V3 said she doesn't have a lidocaine patch for R33. V3 said she hasn't had a patch for him and she did not know why. V3 asked R33 how his pain was. R33 said his pain was currently rated a 4-5/10. R33 said, I have arthritis in my joints. When I sit long, my back starts to hurt. R33's EMAR (Electronic Medication Administration Record), dated August 2024, shows R33's lidocaine patch was not given on 8/1, 8/2, and 8/6/24. On 8/7/24 at 10:18 AM, V20, LPN (Licensed Practical Nurse), said a lidocaine patch is ordered through the facility's pharmacy. V20 said if a lidocaine patch is not applied, then the resident could experience pain. The facility's Administering Medications Policy revised December 2021 shows, Medication shall be administered in a safe and timely manner, and as prescribed. 145563 Page 6 of 11 145563 08/07/2024 The Citadel at Saint Anne Place 4405 Highcrest Road Rockford, IL 61107

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to ensure as needed anti-anxiety medication had a stop date. This applies to 2 of 5 residents (R4 & R95) reviewed for psychotropic medications in the sample of 23. The findings include: 1. R4's physician orders for August 2024 shows, Ativan 0.5 mg (milligrams) tablet, take 1 tablet PO (by mouth) BID (twice daily) PRN (as needed) prior to showers and wound vac changes. The start date of 6/29/24 and no stop date. On 8/7/24 at 11:20 AM, V10, Assistant Director of Nursing, stated she thought PRN (as needed) anti-anxiety medication should have a stop date 14 days after it was ordered. 2. R95's August 2024 Physician Orders and Medication Administration Record both show an active order for Lorazepam 2 MG/ML take 0.5 ML PO (by mouth) every 2 hours as needed (PRN) for anxiety/agitation. The order has a start date of 7/29/24, with no stop date. The facility provided Psychotropic Medication policy last revised 11/2022 shows PRN psychotropic medications should have a stop date of 14 days unless otherwise documented and specified by a physician. 145563 Page 7 of 11 145563 08/07/2024 The Citadel at Saint Anne Place 4405 Highcrest Road Rockford, IL 61107

F 0759 Ensure medication error rates are not 5 percent or greater. 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 administer medications as ordered. There were 26 opportunities with two errors resulting in a 7.69 % error rate. Residents Affected - Few This applies to two of five residents (R33, R110) observed in the medication pass. The findings include: 1. R33's Face Sheet shows he was admitted to the facility on [DATE], with diagnoses including osteoarthritis, repeated falls, and anxiety disorder. R33's Physician Orders, dated August 2024, shows an order for lidocaine 5% patch apply one patch to lower back in the am and off at bedtime. On 8/6/24 at 8:35 AM, V3, RN (Registered Nurse), was giving R33 his morning medications. V3 said she doesn't have a lidocaine patch for R33. V3 said she hasn't had a patch for him and she did not know why. V3 asked R33 how his pain was. R33 said his pain was currently rated a 4-5/10. R33 said, I have arthritis in my joints. When I sit long, my back starts to hurt. 2. R110's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including osteoarthritis, chronic kidney disease, edema, weakness, and history of falling. R110's Physician Orders, dated August 2024, shows Diclofenac sodium 1% gel apply to right knee twice daily. On 8/6/24 at 8:28 AM during morning medication pass, V3, RN (Registered Nurse), administered R110's diclofenac gel to her right and left knee. On 8/7/24 at 10:18 AM, V20, LPN (Licensed Practical Nurse), said physician orders are supposed to be followed when administering medications. V20 said if a resident wants a cream applied elsewhere, then she would notify the nurse practitioner to get new order. V20 also said lidocaine patches are ordered through the facility pharmacy. If a lidocaine patch is not applied on a resident, then the resident could experience pain. The facility's Administering Medication policy, revised December 2021, shows, Medications shall be administered in a safe and timely manner, and as prescribed. The facility's Adverse Effects and Medication Errors Policy last revised December 2021 shows, A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professionals providing services. Examples of medications errors include: Omission-a drug is ordered but not administered, wrong dose, and/or wrong route. 145563 Page 8 of 11 145563 08/07/2024 The Citadel at Saint Anne Place 4405 Highcrest Road Rockford, IL 61107

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to dispose of an expired insulin pen, and failed to label an opened insulin pen with an open date for one of 23 residents (R99) reviewed for medication storage in the sample of 23. The findings include: R99's Physician Orders, dated [DATE], shows an order for insulin aspart sliding scale, insulin glargine pen at bedtime. R99's Electronic Medication Administration Record, dated [DATE], shows R99 is receiving insulin aspart and insulin glargine. On [DATE] at 10:03 AM, there was an insulin aspart pen for R99 that was opened and dated [DATE]. There also was an insulin glargine pen for R99 that was opened, but not dated. On [DATE] at 10:18 AM, V20, LPN (Licensed Practical Nurse), said insulin pens should be dated when they are opened because if it used when its expired, then the medication may not be as effective. V20 said she wasn't sure how long opened insulin was good for. The facility's Administering Medications policy, revised [DATE], shows, When opening a multi-dose container, the open date shall be recorded on the container. The facility's Open Insulin Expiration days policy, not dated, shows an opened insulin aspart (novolog) pen is good for 28 days when it is stored at room temperature. The policy shows an opened insulin glargine (lantus) pen is good for 28 days when stored at room temperature. 145563 Page 9 of 11 145563 08/07/2024 The Citadel at Saint Anne Place 4405 Highcrest Road Rockford, IL 61107

F 0880 Provide and implement an infection prevention and control program. 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 donn personal protective equipment (PPE) in an enhanced barrier precaution (EBP) room, and failed to change gloves and perform hand hygiene in a manner to prevent cross contamination for three of 23 residents (R75, R85, R1) reviewed for infection control in the sample of 23. Residents Affected - Few The findings include: 1. On 8/5/24 at 9:56 AM, V19, CNA (Certified Nursing Assistant), wiped R75's buttocks after R75 had a moderate amount of bowel movement in the toilet. V19 then pulled up R75's clean incontinence brief and pulled up R75's pants. V19 did not change her gloves or perform hand hygiene prior to touching R75's clean items. 2. R85's Care Plan shows she was admitted to the facility on [DATE]. R85's Care Plan with an onset date of 4/19/24 shows, Enhanced barrier precautions due to indwelling medical device, wounds, or MDRO colonization or contained infection. Staff to wear gowns and gloves for high contact resident care. Place EBP signage and PPE supplies at entrance to resident room. Onset date of May 22, 2024-(R85) has a stage 3 and stage 4 pressure injury of the left heel. On 8/5/24 at 1:09 PM, V19, CNA, and V21, CNA, brought R85 to her room to perform incontinence care for R85. There was a sign on the outside of R85's door that showed Enhanced Barrier Precautions all healthcare must wear gloves and gown for the following high contact resident care activities: dressing bathing, providing hygiene, changing briefs or assisting with toileting. R85 was transferred into her bed. R85 had two dressings to her left heel. Neither V19 or V21 had gowns on during incontinence care for R85. V21 wiped stool from R85's rectum. V21 then placed a clean incontinence brief onto R85 and touched R85's body to turn her onto her back. V21 did not change her gloves or perform hand hygiene. 3. R1's Face Sheet shows she was admitted to the facility on [DATE],with diagnoses including alzheimer's disease, dementia, and major depressive disorder. On 8/5/24 at 1:10 PM, V19, CNA, and V21, CNA, performed incontinence care for R1. There was a large amount of urine in R1's incontinence brief. V21 wiped R1's peri area, removed the soiled incontinence brief, placed a new incontinence brief onto R1 and touched R1's shirt and sheets. V21 did not change her gloves or perform hand hygiene. On 8/7/24 at 10:10 AM, V19, CNA, said gloves should be changed after wiping the residents and before placing a new incontinence brief or touching the residents' clothing to avoid causing cross contamination. V19 said R1 has wounds on her feet and that is why she is on enhanced barrier precautions. V19 said R1's wounds are covered, so the staff just need to wear gloves when giving care. On 8/7/24 at 10:18 AM, V20, LPN (Licensed Practical Nurse), said a gown should be worn when providing cares to a resident that is on enhanced barrier precautions so the residents wound does not get infection or staff get urine or stool on them. The facility's Hand Hygiene policy, last revised May 2023, shows, Hand hygiene is practiced before moving from work on a soiled body sit to a clean body sit on the same resident. 145563 Page 10 of 11 145563 08/07/2024 The Citadel at Saint Anne Place 4405 Highcrest Road Rockford, IL 61107

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's Enhanced Barrier Precautions policy, last revised March 2024, shows, EBP is addition to standard and contact precautions, shall be implemented during high-contact resident care activities when caring for resident that have an increased risk for acquiring and/or transmitting a multidrug-resisitant organism (MDRO) such as a resident with wounds, indwelling medical devices and residents with colonization with an MDRO. Enhanced Barrier Precaution expand the use of PPE and refer to the use of gown and glove during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include changing briefs or assisting with toileting. 145563 Page 11 of 11