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.)
(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 2
Event ID:
145751
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
145751
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
PA Peterson at the Citadel
1311 Parkview Avenue
Rockford, IL 61107
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145751
If continuation sheet
Page 2 of 2
