Health inspection·October 16, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation, interview, and record review the facility failed to notify a resident's Power of Attorney regarding a reported fall, new onset of right ankle swelling, and an Xray order. This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 4. The findings include: On 10/15/24 at 11:20 AM, R1 was sitting at a dining table waiting for the noon meal. R1 was pleasant and oriented to person and place. R1's right ankle was swollen when compared to the left ankle. R1's 8/22/24 Quarterly Minimum Data Set (MDS) showed she had severe cognitive impairment with a Brief Interview for Mental Status score of 7 out of 15. The MDS showed she required supervision for ambulating 150 feet. On 10/15/24 at 11:20 AM, R1 stated her ankle was swollen as a result of a fall. R1 stated the fall happened a few months prior. On 10/15/24 at 3:00 PM, V5 stated she was notified, on 10/9/24, that R1 had a swollen right ankle. V5 stated she noted R1 did have a swollen ankle and she asked R1 the cause of the swelling to which R1 replied she had fallen the day prior (10/8/24). V5 stated she notified R1's nurse practitioner and the Director of Nursing of R1's swelling and the reported fall. V5 stated she directed the day nurse to notify the family. V5 stated the nurse did not notify the family. V5 stated the Nurse Practitioner also ordered and X-ray of the ankle and the family was not notified of this test either. V5 stated the importance of notifying the power of attorney (POA) is so they can be informed of the resident's condition and therefore, make better decisions for the resident. V5 stated any notifications should be documented and there is not documentation of the family being notified. On 10/15/24 at 10:15 AM, V8 R1's Power of Attorney stated she was not notified by the facility of R1 falling, R1 having a new onset swollen ankle, or an X-ray being done of R1's ankle. V8 stated she was aware of the X-ray because she received the invoice. V8 stated she was frustrated with the lack of communication by the facility, and she is routinely notified of the care R1 receives by the bills she receives in the mail. V8 stated she would expect to be notified of R1 falling, having a change in condition, or receiving an X-ray. V8 stated she should be notified so she can make better decisions regarding R1's care. V8 stated, during this interview, she had received two phone calls from the facility. V8 stated she would call the facility to determine the purpose of the phone calls. On 10/15/24 at 10:29 AM, V8 stated she called the facility, and they notified her of R1's fall. (6 days after the facility was notified.) Page 1 of 2 145751 145751 10/16/2024 PA Peterson at the Citadel 1311 Parkview Avenue Rockford, IL 61107

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/15/24 at 9:10 AM, V9 R1's Son stated he was not notified, by the facility, that R1 had fallen or there was an Xray being done. On 10/15/24 at 12:35 PM, V2 Director of Nursing (DON) stated, after a resident falls, the provider, herself, and the family should be notified. V2 said the family should also be notified of changes such as a swollen ankle and imaging orders such as an X-ray. R1's 10/9/24 Health Status note from 2:31 PM showed, This writer was informed of swelling to [R1's] foot and notified NP (nurse practitioner) and DON (Director of Nursing). (The note does document a reported fall, or the family was notified.) R1's 10/11/24 Health Status Note from 4:26 PM, showed Radiology reviewed. No foot or ankle fracture or dislocation. (No health status notes between the 10/9/24 and 10/11/24 note.) The facility's Change in Condition policy (dated 6/2024) showed, Requirements for notification of resident, the resident representative, and their physician: .A need to alter treatment significantly .An accident involving the resident, which results in injury and has the potential for requiring physician intervention. The policy continued, Notification is provided to residents and/or the resident representative(s) to promote the right to make informed decisions regarding choices for care and treatment while keeping them informed about their current health status. 145751 Page 2 of 2