Citadel Care Center-Kankakee

In the surveyor’s words

From the most serious findings on record at Citadel Care Center-Kankakee, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 1, 2022

  Based on observation, interview, and record review the facility failed to ensure residents were provided adequate supervision during a community outing. The facility also failed to ensure the staff are knowledgeable about residents at risk for elopement and their individualized supervision needs and complete resident risk assessments and re-assessments timely. This failure resulted in Immediate Jeopardy when R1 and R2 eloped from a community outing without being witnessed by facility staff and were found by motorist on a busy highway impeding traffic. This applies to 3 of 7 residents (R1, R2, R3) reviewed for safety and supervision in the sample of 29. […]

• Actual harm, isolatedF697Jan 12, 2024

  Based on observation, interview, and record review, the facility failed to assess and address pain before and during wound care to a resident. This failure has caused severe pain for one resident during dressing changes. This applies to 1 of 2 residents (R54) reviewed pain management in a sample of 31. The Findings include: R54 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. On 1/10/24 at 2:20 PM, observed V5 (Wound Care Nurse) and V7 (Certified Nursing Assistant - CNA/Memory Care Director) begin to provide wound care to R54's coccyx wound without assessing for pain. Observed V5 and V7 using the mattress linen to pull him up on the bed and R54 complaining of pain, saying, I have too much pain. […]

• No harm, potential for more than minimal, widespreadF812Nov 22, 2024

  Based on observation, interview, and record review, the facility failed to remove expired food items, reseal opened food items, and maintain temperature of freezer to keep foods solid. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 88 residents. On [DATE] at 11:33 AM, V12 (Dietary Manager) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. On [DATE] starting at 11:04 AM, the facility kitchen was toured in the presence of V12 (Dietary Manager) and the following was found: Dry Storage: 1. […]

• No harm, potential for more than minimal, widespreadF868Nov 22, 2024

  Based on interview and record review, the facility failed to maintain a QAA (Quality Assessment and Assurance) committee consisting at a minimum of the director of nursing services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and the infection preventionist. This has a potential to affect all the residents in the facility. The findings include: On 11/21/24 at 09:23 AM, V1 (Administrator) said the Medical Director has not been to any QAA meetings in over a year. […]

• No harm, potential for more than minimal, widespreadF812Jan 12, 2024

  Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 94 residents. On [DATE] at 11:26 AM, V3 (Director of Food and Nutrition Services) said there are no NPO (Nothing by Mouth) residents and all 94 residents eat from the facility kitchen. On [DATE] starting at 10:32 AM, the facility kitchen was toured in the presence of V3 and the following was found: Dry Storage: 1. […]