Citadel of Skokie, the

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a call light accessible for residents. This applies to 5 of 5 residents (R1, R2, R3, R4 & R5) reviewed for call light accessibility in a sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its call light policy by not having the call light within reach. This applies to 1 of 2 residents (R77) reviewed for accommodation of needs in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement wound prevention interventions for a resident (R16) with a recent progression in dementia before a wound developed and failed to ensure pressure reduction devices were applied as ordered after the development of a pressure wound for one out of five residents reviewed for pressure ulcers in a total sample of 23. This failure resulted in R16 developing a blister to the right heel and stage one pressure injury to the right lateral foot. Findings Include: R16 is a [AGE] year old with the following diagnosis: dementia and Parkinson's disease. Due to R16's mental status, R16 could not be interviewed. On 11/20/25 at 2:23PM, V7 (CNA) stated R16 should have heel protector boots on at all times while in bed to prevent the foot wounds from getting worse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Oxygen Administration Policy. Facility failed to follow physician's order for oxygen administration. This deficient practice affects one resident (R8) of three residents reviewed for oxygen administration in a total sample of 23. Findings Include On 11/18/25 at 10:15AM, observed R8 in bed, oxygen concentrator at bedside. Oxygen concentrator is set to 3L (Liters) per minute via nasal cannula. On 11/18/25 at 11:00AM, observed and confirmed with V5 (Nurse) that R8's oxygen setting is at 3L per minute. V5 also stated that R8 is on continuous oxygen administration at 3L per minute. R8 is a [AGE] year-old male resident under hospice care for diagnosis of COPD (Chronic Obstructive Pulmonary Disease) started on 7/18/25. Physician order sheet reviewed. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician's order to remove an indwelling urinary catheter for a resident diagnosed with urinary retention and failed to review a resident's hospital records upon admission for the diagnosis and follow up care for the indwelling urinary catheter. These failures affected one (R1) of four residents reviewed for improper nursing care. This failure resulted in R1 developing abnormal lab values with urinary retention and UTI (Urinary Tract Infection), subsequently requiring hospitalization.

Inspectors wroteBased on interview and record review the facility failed to provide care and services according to accepted standards of practice by failing to obtain a physician's order to remove an indwelling urinary catheter for a resident diagnosed with urinary retention and failed to review a resident's hospital records upon admission for the diagnosis and follow up care for an indwelling urinary catheter. These failures affected one (R1) of four residents reviewed for improper nursing care.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure R93 was not verbally abusive toward three of 18 residents (R6, R25, and R53) present in the facility dining area.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide consistent monitoring and supervision for a verbally aggressive resident (R93) throughout the entire lunchtime meal in-service in the second floor dining room. This failure affects three of eighteen residents (R6, R25 and R52,) in which R93 was verbally aggressive toward while staff was not monitoring R93.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications per facility policy for one of two residents (R40) reviewed for medication administration on the total sample of 42.

Inspectors wroteBased on interview and a record review, the facility failed to prevent an incident of staff to resident sexual assault and inappropriate exposure. This affected one of three residents (R1) reviewed for sexual assault and inappropriate exposure. This failure resulted in V6 forcibly pushing R1 down onto her back, grabbing her breast, undoing his clothing and exposed his penis to attempting to rape R1. R1 said, she felt hurt and wished for death. R1 said, she felt victimized, traumatized, and feared for her safety. The Immediate Jeopardy began on 04/09/24 when V6 exposed his penis and sexually assaulted R1. V1 (Administrator), V2 (Director of Nursing) and V14 (Chief Operating Officer) was notified of the Immediate Jeopardy on 04/18/24 at 11:40AM. [...]

Inspectors wroteBased on interview and record review the facility failed to have effective system in place to prevent a resident from leaving the facility unauthorized on two different occasions. This affected one of three residents (R1) reviewed for supervision and elopement. This failure resulted in R1 being buzzed out of the facility with a visitor without staff knowledge on 01/05/24, and R1 able to leave the facility without staff knowledge on 03/11/24 after a staff member failed to ensure the door was closed securely after entering. The Immediate Jeopardy began on 01/05/2024 when R1 left out the facility when V14 buzzed visitors out of the facility and was found disorient and falling on the ground by local police, R1 also left the faciity on [DATE] and found disoriented and falling on the ground by the local police. [...]

Inspectors wroteBased on interview and record review the facility failed to follow the order of the primary care provider by not ordering a STAT Xray after a fall incident. This affected one of three residents (R4) reviewed for following the physician orders. This failure resulted in a 13-hour delay in R4 having an Xray conducted subsequently resulting in a diagnosis of 5 right side rib fractures and an acute fracture of right elbow.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow enteral feeding administration physician order for 1 (R3) of 3 residents reviewed for enteral tube feed management in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their food service and safety policies by not ensuring refrigerated foods were properly stored; food items in the cooler not labeled and dated; foods not removed from the cooler after disposal date; and not maintaining proper general cleanliness and organization in the kitchen. These failures have the potential to affect all residents who reside in the facility and receive services from the kitchen.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to administer medications as ordered. There were 25 opportunities with two errors resulting in 8% medication error rate. These failures applies to one (R65) resident observed during the medication administration on the sample list of 51.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who required transmission based precautions was placed on contact isolation after readmitting from the hospital. This failure applied to one (R307) of one resident reviewed for infection control on the sample list of 51.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to post a notice of availability and failed to provide access for residents to the most recent Federal or State Survey conducted and any subsequent plans of correction. This failure has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to inform residents individually and through postings of their grievance process and procedures including contact information of the grievance official, reasonable expected time frame for reviewing and responding to grievances, the right to obtain a written decision regarding his or her grievance, and the contact information of independent entities such as the state agency with whom grievances may be filed. This failure has the potential to affect all residents residing in the facility.