Health inspection·December 11, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat a resident in a dignified manner for 1 of 18 residents (R9) reviewed for dignity in the sample of 18. The findings include: R9's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including parkinsons, chronic obstructive pulmonary disease, contusion of left ankle, and generalized anxiety disorder. R9's Care Plan with an admission date of May 28, 2021 shows R9 has emotional and spiritual distress due to hopelessness and lack of family support. R9's Care Plan dated February 9, 2022 shows to approach resident warmly and positively and in a calm manner, calmly talk with resident and offer reassurance prior to initiating cares. On December 9, 2024 at 10:14 AM, R9 went into her room and was asking to go into her bed. R9 was moaning and saying Oh my God. R9's moans were audible from across the hall. At 10:44 AM, V8 CNA (Certified Nursing Assistant) walked into R9's room and stood at the foot of R9's bed. V8 said, Stop, please stop. Nobody wants to hear that. At 10:46 AM, V9 CNA entered R9's room as well. R9 did not have her incontinence brief on. V8 and V9 were attempting to put R9's incontinence brief back on. R9 kept saying no. V9 went right up to R9's left ear and said loudly that they were going to replace her incontinence brief. R9 winced and looked at V9. On December 11, 2024 at 8:06 AM, V2 DON (Director of Nursing) said R9 is not hard of hearing. V2 said that R9 can hear without having to have someone come close to her ear. V2 said she expects staff to re-approach the resident at a later time if they are having any type of behavior. V2 said that V8 and V9's responses were not appropriate. The facility's Quality of Life-Dignity policy revised on December 2021 shows, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Associates shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not 'labeling' or referring to the resident by his or her room number, diagnosis, or care needs. Page 1 of 8 145935 145935 12/11/2024 The Citadel at Saint Joseph Village 659 East Jefferson Street Freeport, IL 61032

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review the facility failed to safely transfer a resident by using a gait belt for 1 of 18 residents (R36) reviewed for safety in the sample of 18. Residents Affected - Few The findings include: R36's Care Plan shows, Gait belt with all transfers .Transfers with assist of 1 person. On 12/9/24 at 1:01 PM, V18, Certified Nursing Assistant (CNA) brought R36 to his room. V18 positioned R36's wheelchair next to his bed. V18 assisted R36 to a standing position by lifting under his arm. V18 instructed R36 to turn while she guided his hips with her hands to the appropriate position to get into bed. V18 did not apply a gait belt on R36 during the transfer from his wheelchair to the bed. On 12/10/24 at 1:53 PM, V19 (CNA) said that R36 is a one person assist for transfers and staff should use a gait belt and his walker for the transfer. On 12/10/24 at 1:53 PM, V2 (Director of Nursing) said that gait belts should be use with all transfers for the resident's safety if they start to fall. The facility's Restorative Nursing-Transfer Program Policy revised on 12/2017 shows, Use gait belt and other appropriate transfer aids 145935 Page 2 of 8 145935 12/11/2024 The Citadel at Saint Joseph Village 659 East Jefferson Street Freeport, IL 61032

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Actual harm Based on observation, interview, and record review the facility failed to provide physician ordered intervention that maintained the patency of a CVC-Central Venous Catheter for 1 of 1 resident (R2) reviewed for parental fluids in the sample of 18. This failure resulted in the occlusion of R2's catheter and the need for replacement. Residents Affected - Few The findings include: R2's Current Minimum Data Set on 12/11/2024 shows, R2 is cognitively intact. On 12/11/24 at10:17AM, R2 pulled up her pant leg to reveal a CVC-Central Venous Catheter in her left upper thigh that had a blue colored locking cap labeled 3.6 milliliters and a red colored locking cap labeled 3.5 milliliters. The clear lumens of the red capped and blue capped catheter had dark red blood in the tubing. At 11:00AM, V21 RN (Registered Nurse) flushed R2's CVC and removed the blood from the two lumens. On 12/10/24 at 11:49 AM, R2 said, I had to get my catheter replaced again due to it being clogged. They are supposed to flush it and are not doing it, so it keeps getting clogged. On 12/11/24 at 10:18AM, R2 said, they flushed my line yesterday, they have not flushed it today. On 12/11/2024 at 10:21AM, V23 (LPN-Licensed Practical Nurse) said, I do not flush R2's femoral catheter. On 12/11/24 at 10:22AM, V21 (RN) said, LPN's do not flush CVC. R2's CVC is flushed with Normal Saline daily and as needed when there is blood in the line. On 12/11/24 at 11:17 AM, V2 (DON-Director of Nurses) said, there is no training for CVC flushing. If the staff are not confident with the procedure they will call the DON. We have a program in our computer system that provides instruction for CVC flushing. Any topic the nurse is uncertain the nurse can look up and it will provide education. R2's Medication Administration Record dated November 2024 shows, Normal Saline Flush 10 milliliter syringe flush CVC with 10 milliliters once daily every day. Start 10/30/2024. November 1st Not Administered. 7th Not Administered by V21 (RN). 8th Not Administered. 9th Not Administered. 10th Not Administered by V4 (LPN). 14th Not Administered. 15th Not Administered. 16th Not Administered. 17th Not Administered. 19th Not Administered. 20th Not Administered. 24th Not Administered. 25th Not Administered. 27th Not Administered. 28th Not Administered. 30th Not Administered. Heparin 500 unit per 5 milliliters Heparin Lock both Ports of CVC with 2.4 milliliters weekly with dressing change. Start date 07/26/24. October 1st Not Administered. 8th Not Administered. 15th Not Administered. 22nd Administered by V24 (LPN). 29th Not Administered. R2's Medication Administration Record dated December 2024 shows, Normal Saline Flush 10 milliliter syringe flush CVC-central venous catheter with 10 milliliters once daily every day at 8:00AM. Start 10/30/2024. December 1 Not Administered. 2nd Administered. 3rd Not Administered. 4th Not Administered. 5th Administered. 6th Not Administered. 7th Administered. 8th Not Administered. 9th Administered. 145935 Page 3 of 8 145935 12/11/2024 The Citadel at Saint Joseph Village 659 East Jefferson Street Freeport, IL 61032

F 0694 Level of Harm - Actual harm On 12/11/24 at 1:15 PM, V4 (LPN) said, most likely the nurses that documented on 12/02, 12/05, 12/07, 12/09/2024, got click happy, the line occluded on 11/27/24 at 1:33PM, the nurse called the surgeon and was told not to continue flushing it. The nurse on those dates documented doing the flush but the flush was not done, they were, click happy with their documentation. Residents Affected - Few R2's Departmental Notes dated 11/27/2024 at 1:33PM, shows, resident was flushed in AM. 6 milliliter flush due to resistance. Called surgeon which advised no more flushing. Dressing is saturated with blood and feels boggy to touch. Awaiting MD (Medical Doctor) phone call for further instruction. Signed by: (V25 LPN). R2's Central Venous Catheter Placement Narrative by V26 (Medical Doctor) dated 12/09/2024 at 2:30PM, shows, after local anesthesia was obtained, the retention cuff of the existing dialysis catheter was bluntly dissected free. It should be noted that the clear portions of both ports were noted to be completely filled with clot. This was noted on every catheter exchange indicating that this catheter is likely not being flushed and locked properly with being allowed to flow back into the lumen of the catheter where it clots. The catheter was aspirated and cleared of a large amount of soft clot. Contrast was infused which demonstrated some irregularity at the level of the catheter tip. The decision was made to place a slightly longer catheter. The remainder the catheter was removed over a wire. Conclusion: Again, noted is thrombus filling the clear portions of both lumens of the catheter indicating that this catheter is not being flushed and locked with heparinized saline correctly. Blood is being allowed to flow backward within the lumen of the catheter and clotting resulting in obstruction of the catheter. 145935 Page 4 of 8 145935 12/11/2024 The Citadel at Saint Joseph Village 659 East Jefferson Street Freeport, IL 61032

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to administer medications as ordered. There were 37 opportunities with 4 errors resulting in a 10.81 % error rate. This applies to 1 of 3 residents (R2) observed in the medication pass. Residents Affected - Few The findings include: 1. R2's December Medication Administration Record (MAR) showed that R2 had an order for Diltiazem 30 milligrams (mg) to be given at 8:00 AM for hypertension. There was no hold parameters on the order. On 12/10/24 at 8:30 AM, V10 (Licensed Practical Nurse) administered R2's morning medications. R2's blood pressure was 160/75 and her pulse was 58. V10 did not administer R2's Diltiazem. V10 stated that she was going to hold R2's Diltiazem because her pulse was less than 70. R2's clinical records were reviewed on 12/11/24 and did not contain any documentation that the physician was notified that R2's Diltiazem was held on 12/10/24. 2. R2's December MAR shows an order for Timolol Maleate 0.5 % eye drops-one drop to left eye every morning at 8:00 AM due to changes in retinal vascular appearance. On 12/10/24 at 8:30 AM, V10 administered R2's Timolol Maleate 0.5 % eye drops into both eyes. 3. R2's December MAR shows an order for Milk of Magnesia-Take 15 milliliters (mL) every other day due to drug induced constipation. The MAR shows that it was given on 12/9/24 and is not due to be given on 12/10/24. On 12/10/24 at 8:30 AM, V10 administered Milk of Magnesia 30 mL to R2. 4. R2's December MAR shows an order for Vitamin D3 3,000 units to be given daily at 8:00 AM. On 12/10/24 at 8:30 AM, V10 did not administer R2's Vitamin D3 3,000 units as ordered. On 12/10/24 at 1:58 PM, V2 (Director of Nursing) said that all medications should be given as ordered. V2 said that if a nurse is holding a medication that does not have parameters, they should contact the physician to let them know why they are holding it and get approval to not give the medication. The facility's Administering Oral Medications Policy revised 12/2017 shows, Verify that there is a physician's medication order for this procedure Select the drug from the unit dose drawer or stock supply, check the label on the medication and confirm the medication name and dose with the MAR. Check the medication dose. Re-check to confirm the proper dose . 145935 Page 5 of 8 145935 12/11/2024 The Citadel at Saint Joseph Village 659 East Jefferson Street Freeport, IL 61032

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure a resident received the correct insulins as ordered by an endocrinologist for 1 of 1 resident (R2) reviewed for significant medication errors in the sample of 18. Residents Affected - Few The findings include: On 12/9/24 at 9:25 AM, R2 said that the facility did not transcribe her insulin orders right from her endocrinology appointment a few months ago. R2's After Visit Summary (AVS) from her endocrinologist dated 9/24/24 shows, The following issue was addressed: Type 1 diabetes mellitus with polyneuropathy .Please change basaglar (long-acting insulin) dose to 10 units in the morning and 16 units in the evening. Adjust the meal time novolog (short-acting insulin) dose to 10 units with meals and continue the sliding scale R2's September MAR shows that on 9/24/24 an order was placed for: Insulin Glargine (long-acting insulin) 20 units in the AM and Insulin Lispro (short-acting insulin) 16 units in the evening. R2's MAR shows that she received the insulins until it was discontinued on 9/30/24. R2's September MAR shows that on 9/24/24 an order was placed for: Novolin N (Intermediate-acting insulin) 10 unit at meals. R2's MAR shows that she received the insulin until it was discontinued on 9/30/24. On 12/11/24 at 11:27 AM, V2 (Director of Nursing) said that the nurses should follow the medication orders on the AVS when transcribing new orders. V2 said that novolog and novolog N are two different types of insulin and are not interchangeable. V2 said that insulin's may be ordered under different brand names based on what the pharmacy carries but it should always be replaced with the same type of insulin. On 12/11/24 at 11:30 AM, V20 (Licensed Practical Nurse) said that she does medication audits for the residents at the end of each month. V20 said that she found R2's insulin ordering error during her medication audits and ordered the correct insulins. 145935 Page 6 of 8 145935 12/11/2024 The Citadel at Saint Joseph Village 659 East Jefferson Street Freeport, IL 61032

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review the facility failed to ensure pureed Swiss steak was a smooth, uniform texture that does not require chewing for 4 of 4 residents (R2, R35, R52, R78) reviewed for pureed diets in the sample of 18. The findings include: The facility provided list of residents on a pureed diet shows that R2, R35, R52, and R78 receive a pureed diet. On 12/9/24 at 11:28 AM, V11 (Cook) began pureeing the Swiss steak for lunch. V11 said the texture she is looking for with the pureed products is a consistency similar to mashed potatoes. V11 ran the food processor for a few short minutes before using a spatula to put the pureed Swiss steak into a steam table pan. The pureed Swiss steak appeared slightly chunky while V11 was transferring the product from the food processor into the steam table pan. V11 did not taste test the pureed Swiss steak when finished. On 12/9/24 at 1:12 PM, facility provided test tray of pureed Swiss steak, pureed broccoli, pureed mashed potatoes, and pureed bread pudding was reviewed. The pureed Swiss steak was gritty with small granules throughout the product, prompting the need to chew before swallowing. On 12/9/24 at 1:21 PM, V6 (Dietary Manager) tested the pureed Swiss steak from the facility provided test tray and V6 was noticeably chewing the pureed Swiss steak. V6 said the pureed Swiss steak was gritty and that staff should be taste testing the product every time before finishing the puree. Facility Modified Texture Foods policy dated 1/24 states, . Foods requiring modification to a puree texture will have a smooth texture. 145935 Page 7 of 8 145935 12/11/2024 The Citadel at Saint Joseph Village 659 East Jefferson Street Freeport, IL 61032

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure a spatula and food processor components were washed and sanitized in a manner to prevent cross-contamination for 4 of 4 residents (R2, R35, R52, R78) reviewed for pureed diets in the sample of 18. The findings include: The facility provided list of residents on a puree diet shows that R2, R35, R52, and R78 receive a pureed diet. On 12/9/24 at 11:28 AM, the facility had approximately six food processor pitchers, two food processor lids, and three food processor blades for use at the puree station. On 12/9/24 at 11:28 AM, V11 (Cook) started to puree the Swiss steak for lunch. When V11 finished the Swiss steak, V11 placed the food processor pitcher with the blade and lid into the sink adjacent the puree prep station. V11 ran hot water into the pitcher and grabbed the spatula and ran it underneath the running hot water. V11 then grabbed a new food processor pitcher, blade, and lid and started to puree the mashed potatoes for lunch. When finished with the mashed potatoes, V11 used the spatula that was run under the water and used it to transfer the mashed potatoes from the pitcher to a steam table pan. At 11:34 AM, V11 grabbed the food processor blade from the first food processor blender that was in the sink under hot running water and placed it in a new food processor pitcher to begin pureeing the broccoli for lunch. V11 also continued the same process with the spatula, using the same spatula the entire time. When finished with the pureed broccoli, V11 used the contaminated spatula to transfer the pureed broccoli from the food processor blender to a steam table pan. At 11:37 AM, V11 grabbed a new food processor blender and a new food processor blade to begin the process for mechanical soft Swiss steak. V11 grabbed one of the previously used lids, ran it under the hot water in the sink, and placed it on top of the food processor to start the mechanical soft Swiss steak. On 12/10/24 at 9:37 AM, V6 (Dietary Manager) said when doing purees and mechanical soft foods, the cook should have either a new container with lid and blade for each item or they should be washing, rinsing, and sanitizing each component before using it again. V6 said this is done in order to reduce the risk of cross-contamination. Facility provided Cleaning of Food and Nonfood contact Surfaces policy dated 1/24 states, . To prevent cross-contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of operation during which time contamination may have occurred. 145935 Page 8 of 8