Citadel of Glenview,the

Inspectors wroteBased on observation, interview, and record review the facility failed to complete infectious screening assessment for resident started on antibiotics and formulate a care plan for its usage. The facility also failed to monitor behavior and medication side effects for resident on psychotropic medications. This deficiency affects all 4 residents (R3, R8, R123 and R129) in the sample of 25 reviewed for Unnecessary medications.

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect , dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, and failed to provide a dignified dining experience for 1 of 3 residents observed during meal service in the resident's room for 1 of 3 resident's (R13) in a sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure prevention of using physical restraints to unnecessarily impede R9's freedom of movement affecting 1 of 1 resident (R9) reviewed for freedom of restraint in a total sample of 25. Findings Include:On 7/23/2025 at 12:45 PM, R9 was seated in the wheelchair with self-releasing belt applied around the chest-abdominal area. V18 (Korean Program Director) translated to R9 to demonstrate how to release the self-releasing belt. R9 was not able to remove the belt independently and was not able to follow command. V18 stated R9 is not able to release the belt on her own. On 7/23/2025 at 2:05 PM, V2 (Director of Nursing) stated self-releasing belt is removed by the resident without assistance from staff. V2 said R9 uses the self-releasing belt to prevent her from standing up. [...]

Inspectors wroteBased on interview and record review the facility failed to refer a resident to the appropriate state designated authority for a PASARR level 2 screening for evaluation and determination of newly evident serious mental illness related condition, for two of four residents (R12, R62) reviewed for a PASARR level 2 screening in a sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Preadmission Screening and Resident Review (PASARR, Level I and Level II) was conducted prior to admission affecting 2 of 2 residents (R91, R122) reviewed for PASARR in a total sample of 25. Findings Include:1. On 7/23/2025 at 12:35 PM, V19 (admission director) stated that the social service department should be the one to complete PASARR of every residents in the facility. On 7/23/2025 at 2:00 PM, V1 (Administrator) stated there was no PASARR completed for R122 prior to admission in the facility. V1 said that he is aware that PASARR needs to be done for all admissions to determine any specialized services to be provided. Review of records of R122 read; [AGE] year-old female patient initially admitted in the facility on 5/20/2022. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care to dependent resident. This deficiency affects one (R129) of three residents in the sample of 25 reviewed for ADLs (Activity of Daily Living) Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that no treatment medication is left at bedside without physician order. This deficiency affects one (R8) of three residents in the sample of 25 reviewed for Medication safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to place EBP (Enhanced Barrier Precaution) signage and set up for resident on dialysis. The facility also failed to clean and disinfect vital signs equipment after resident use. This deficiency affects three ( R55, R7, R129) of three residents in the sample of 25 reviewed for Infection Control Management.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement monitoring of antibiotics. This deficiency affects one (R14) of three residents in the sample of 25 reviewed for Antibiotic Stewardship Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was assessed for self administering medications for 1 of 3 residents (R1) reviewed for medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify behaviors, failed to notify the psychiatric nurse practitioner of behaviors, and failed to provide appropriate behavioral health services to a resident with multiple mental health diagnoses for 1 of 3 residents (R1) reviewed for behavioral health services. This failure has resulted in R1 refusing to allow facility staff in her room, covering areas of the walls in her room with aluminum foil, towels, sheets, and covering the ceiling vent with plastic wrap.

Inspectors wroteBased on observations, interviews and record review, the facility failed to properly clean and sanitize service and dishware. This deficiency has the potential to affect 120 residents receiving food from the kitchen.

Inspectors wroteBased on observations, interview and record review, the facility failed to follow their policy on garbage disposal by failing to close lids of the dumpster. This deficiency has the potential to affect all 122 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident personal refrigerator temperatures were maintained at 41 degrees Fahrenheit, failed to clean personal refrigerators regularly to maintain a safe and sanitary environment for food storage, failed to date/label food items, and failed to Discard expired food items after 6 days for 4 residents (R72, R73 R112, R67) reviewed for personal refrigerators in a sample of 25.

Inspectors wroteBased on interview, and record review the facility failed to follow their resident rights policy by failing to allow one resident (R90's) durable power of attorney for health care, to enter the facility to visit R90. 1 resident (R90) out of 3 reviewed for resident rights in the sample of 25. Findings Include, R90's clinical record documents in part; R90 is a [AGE] year-old with medical diagnosis of dementia, osteoarthritis, essential hypertension, chronic kidney disease, dysphagia, anxiety and adult failure to thrive. Minimum data set [MDS] Brief Interview Mental Status score [5] dated (10/11/22) indicates R90 is severely cognitively impaired. On 9/19/23 at 3:30 PM, V34 [R90's Durable Power of Attorney of Health Care] per phone interview stated, I drive from down state Illinois and stay in a hotel for a week. During that time, I stay with R90 from 8am to 8PM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper grooming for one resident (R322) in a sample of 25 residents reviewed for activities of daily living care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper use of pressure relieving devices. This failure affected one resident (R322) out of 3 reviewed for air mattress pressure in a sample of 25 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their smoking safety policy, Failed to ensure that smoking materials are not kept by resident at bedside. Failed to ensure that resident was evaluated upon admission for safety of smoking. Failure to ensure that resident was re-evaluated for their ability to smoke safely on readmission, quarterly or annual basis. These failures affected 1 resident (R69) of 5 residents reviewed for smoking in the sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to follow a physician order for fluid restrictions. This failure affected 2 residents (R12, R43) out of 5 reviewed for nutrition care in a sample of 25.

Inspectors wroteBased on observation, interview and record review the facility failed to date and change oxygen equipment every 7 days per facility policy and ensure oxygen cannula tubing is placed in a bag when not in use. These failures apply to 1 resident (R69) out of 5 reviewed for oxygen therapy in a sample of 25.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain accurate documentation for 1 resident (R275) of 11 residents who received controlled substances from first floor west unit cart.

Inspectors wroteBased on interview and record review, the failed to follow their policy and obtain consent for a psychotropic medication for one resident (R63) of five residents reviewed for consents in a sample of 25 residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to label open insulin vials for 2 residents (R276, R323) reviewed for medication labels on 1 of 6 medication carts.