Health inspection·December 13, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide assistance with oral and/or denture care for one (R7) of three residents reviewed for activities of daily living (ADL); and the facility failed to follow its policy and procedures by not ensuring that a resident with a self-care deficit (R7) received the necessary assistance to maintain oral hygiene. Residents Affected - Few The findings include: Review of R7's face sheet indicated resident admitted to the facility on [DATE] with a past medical history not limited to: dementia, type 2 diabetes mellitus, peripheral vascular disease, mild cognitive impairment, anxiety, hypertension, and history of infectious and parasitic diseases. Review of R7's Minimum Data Set, Section C for Cognitive Patterns (page 9) dated 11/15/2024 documented Brief Interview for Mental Status (BIMS) score of 5/15 which indicates impaired cognition. Section GG for Functional Abilities (page 21) dated 11/15/2024 documented that resident requires partial to moderate assistance with oral hygiene, to insert and remove dentures into and from the mouth and manage dentures soaking and rinsing with use of equipment. On 12/12/2024 at 10:51 AM, observed R7 in his room seated in a wheelchair. Observed R7's upper and lower dentures in place that appeared unclean. R7 indicated that his dentures have been in for about week now and he himself has not brushed them and no staff have taken his dentures out to clean them either. On 12/12/2024 at 10:56 AM, V9 (Licensed Practical Nurse) who was R7's nurse said he wears dentures, and she has helped him a few times in the past remove his dentures at night and has brushed them for him. She added that dentures should be removed daily, usually at night to be cleaned and soaked overnight. V9 added that when a resident refuses to remove their dentures, staff should reattempt multiple times and the refusal is documented in their progress notes. On 12/12/2024 at 2:15 PM, V2 (Director of Nursing) said she just talked to R7, and he refused to remove his dentures at this time. R7 was then educated by V2 on the importance of removing dentures and receiving oral care. Per V2 (DON), R7 verbally agreed to allow staff to remove dentures this evening. V2 then provided one shower sheet for the last thirty days dated 12/10/2024 that documented R7 refused denture care. Review of R7's progress notes for the last 30 days showed no documented refusals of R7 not taking out his dentures and/or refusing oral care. On 12/12/2024 at 3:10 PM, V2 (Director of Nursing) said that oral care should be provided daily to each resident and is usually done with morning cares but can be performed at any time throughout the (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 12/13/2024 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)