Health inspection·June 13, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a surgical incision was cleansed per physician's order for 1 of 3 residents (R1) reviewed for physician's orders in the sample of 5. Residents Affected - Few The findings include: R1's medical record showed she was admitted to the facility on [DATE] with diagnoses to include fibromyalgia, atherosclerotic heart disease, surgical aftercare following cardiac surgery, myocardial infarction, presence of aortocoronary bypass graft, asthma with acute exacerbation, chronic pain syndrome, muscle wasting, muscle weakness, hypertension, major depressive disorder, obstructive sleep apnea, and hypokalemia. R1's facility assessment dated [DATE] showed she had no cognitive impairments and required partial to moderate assist with most cares. R1's acute care hospital discharge packet dated 5/27/25 showed . Wound Care Orders . Monitor your wounds for signs and symptoms of infection, including redness, swelling, drainage, and odor. If you notice these symptoms call your surgeon's office. Wash incision daily with soap and water. Do not rub the site. Do not use lotions and/or ointments on incision . R1's May and June eTAR (electronic Treatment Administration Record) showed no order entered to wash her incision daily with soap and water. R1's record only included monitoring of the incision site. R1's medical record showed no evidence that her midline incision to her chest was cleaned during her stay from 5/28/25 through 6/9/25. On 6/13/25 at 3:03 PM, V3 (Registered Nurse/Wound Care Nurse) said when R1 was admitted to the facility she was told her incision was to be open to air. V3 said she gets report from the nurse that a resident has a wound upon admission and she will go through the admission paperwork to confirm wound care orders. V3 said she must have overlooked R1's order to wash her incision daily. V3 said there should have been an order entered to clean R1's incision site. V3 said the purpose of washing R1's incision daily would be to keep the area clean and free of germs and prevent infection. On 6/13/25 at 2:51 PM, V2 DON (Director of Nursing) said she was not aware there was an order for wound care. V2 said decisions on how to proceed with orders of that nature go through V3 the wound care nurse. V2 said V3 would typically review the orders and coordinate with either the facility's wound care doctor or nurse practitioner to determine a course of treatment. V2 said it is important to have someone following the wounds because there needs to be orders to ensure monitoring and making sure the wound is healing and having someone to communicate with for orders. The facility's policy and procedure with approval date of 01/2024 showed, Heath Care Provider Page 1 of 2 145935 145935 06/13/2025 The Citadel at Saint Joseph Village 659 East Jefferson Street Freeport, IL 61032

F 0684 Level of Harm - Minimal harm or potential for actual harm Orders . Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Supervision by a Physician; A. A current list of orders must be maintained in the clinical record of each resident . F. Treatment Orders - when recording treatment orders, specify the treatment, frequency, and duration of the treatment . Residents Affected - Few 145935 Page 2 of 2