Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Citadel At Casa Scalabrini during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls sustained a fracture after a CNA failed to follow therapy recommendations for hands-on assistance during transfers. The resident was being weighed in the shower room when the CNA let go of the gait belt, leading to a loss of balance and a fall. The facility's records indicated that the resident required moderate assistance for transfers, which was not provided at the time of the incident.
The facility's kitchen failed to maintain sanitary practices, affecting food safety for 172 residents. Dented cans were improperly stored, and a cooler malfunction led to perishable items being kept at unsafe temperatures. Mold was found in another cooler, and food handling practices were inadequate, with staff unaware of correct food temperatures. Personal items were stored in the kitchen, and staff did not adhere to hygiene policies, compromising food safety.
The facility failed to conduct weekly chlorine level tests as required by its Water Management Plan for Legionella, and did not adhere to Enhanced Barrier Precautions for a resident with wounds. Staff were observed providing care without wearing necessary gowns, contrary to the facility's infection control policy.
The facility failed to assist several residents with personal hygiene and grooming, despite their need for total assistance due to conditions like paraplegia, dementia, and quadriplegia. Observations revealed long fingernails with substances underneath and overgrown facial hair, indicating a lack of care. The DON acknowledged the responsibility to assist with ADLs, yet these needs were unmet.
The facility failed to provide the appropriate menu items for residents on mechanical soft and pureed diets, as they did not receive the planned soft cooked hot vegetables and pureed cooked hot vegetables. Additionally, residents on mechanical soft diets were served dry ground pork roast without the required gravy. The dietary manager and cook confirmed the gravy was not prepared, and the dietitian stated the facility should follow the menu spreadsheets.
The facility failed to include required language in their arbitration agreements, affecting 51 residents. The agreements signed before March 4, 2025, did not state that signing was not a condition for admission. Some residents did not recall signing or understanding the agreement. The facility updated the agreement, but those who signed earlier were not asked to sign the new version.
The facility failed to follow physician orders for a resident requiring an ace bandage for hand swelling and did not assess another resident for supportive devices despite a contracted arm. Observations showed inconsistent application of the bandage for one resident, while the other was only evaluated for a splint after surveyor intervention.
Two residents with hemiplegia and hemiparesis were not provided with necessary splints and devices to maintain ROM. One resident had limitations in the left upper extremity and was observed without a splint or device, while another had limitations in the right upper extremity and also lacked necessary support. The therapy department recommended appropriate devices only after surveyor intervention.
Failure to Follow Therapy Recommendations Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to therapy recommendations for a resident, resulting in a fall and subsequent injury. The resident, who was severely cognitively impaired and required moderate assistance for transfers and ambulation, was being weighed by a CNA in the shower room. The CNA, who was responsible for assisting the resident, let go of the gait belt to obtain an accurate weight, contrary to the therapy recommendations that required hands-on assistance at all times. This lapse in supervision led to the resident losing balance and falling, causing a fracture of the left fibula. The resident's medical history included cerebral infarction, repeated falls, and osteoarthritis, among other conditions, which contributed to their high fall risk. The facility's records indicated that the resident's weights were typically taken while in a wheelchair, and the therapy discharge summary explicitly recommended assistance for safe transfers. Despite these precautions, the CNA's failure to maintain contact with the gait belt during the weighing process directly led to the resident's fall and injury. The orthopedic doctor confirmed that the injury could have been prevented if the staff had followed the therapy recommendations for hands-on supervision during transfers.
Sanitary Violations in Facility Kitchen
Penalty
Summary
The facility failed to adhere to sanitary practices in the kitchen, affecting the food safety for 172 residents. During an inspection, dented cans were found stored improperly in both the dry storage area and a walk-in cooler. Additionally, several cans lacked delivery dates, indicating a lapse in inventory management. The walk-in cooler was malfunctioning, with temperatures recorded at 54 and later 58 degrees Fahrenheit, well above the recommended 41 degrees Fahrenheit, yet the perishable items remained inside. Mold was observed in another cooler, and food items were not properly covered, posing a contamination risk. In the kitchen, several hygiene violations were noted. Cutting boards were stored with unknown debris, and a cook was observed preparing food without a beard cover, contrary to facility policy. Food temperature monitoring was inadequate, with mashed potatoes initially served at 82 degrees Fahrenheit, below the required 135 degrees Fahrenheit for hot foods. The cook and dietary manager were unaware of the correct reheating temperature, which should be 165 degrees Fahrenheit. Additionally, dietary aides were seen eating and storing personal items in the kitchen, and one aide was not wearing gloves while serving food. The facility's dietary policies were not followed, as evidenced by improper storage of dented cans, failure to maintain appropriate refrigeration temperatures, and inadequate food handling practices. The dietary manager and staff demonstrated a lack of knowledge regarding food safety standards, contributing to the deficiencies observed. These lapses in protocol and oversight compromised the sanitary conditions of the kitchen and the safety of the food served to residents.
Failure to Follow Water Management and Infection Control Protocols
Penalty
Summary
The facility failed to adhere to its Water Management Plan for Legionella, as evidenced by the lack of weekly chlorine level testing in the water system. The Maintenance Director, V15, confirmed that while water temperatures were regularly tested, chlorine levels were not. The Regional Maintenance Director, V14, corroborated this, stating that a water company conducted monthly chemical tests, but these did not include chlorine levels. The facility's Water Management Plan, dated October 18, 2024, explicitly required weekly chlorine testing to mitigate the risk of microbial growth in both cold and hot water systems, which was not being performed. Additionally, the facility did not follow its policy for Enhanced Barrier Precautions (EBP) for a resident, R151, who had wounds requiring such precautions. Despite an order and care plan indicating the need for EBP, staff members V19 and V20 were observed providing care to R151 without wearing the required gowns. The Director of Nursing, V3, and the Infection Preventionist, V16, acknowledged that EBP should have been implemented when R151's wound was assessed as open, and that staff should have donned gowns and gloves for high-contact activities. The facility's policy on Enhanced Barrier Protection, dated May 2022, outlined the necessity for healthcare providers to wear gowns and gloves for high-contact resident care activities to prevent the spread of infections. This policy was not followed, as evidenced by the staff's failure to wear appropriate personal protective equipment while caring for R151, who had an open wound and required EBP. The lack of adherence to these protocols represents a significant deficiency in infection control practices at the facility.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene and grooming for several residents who were identified as needing such assistance. This deficiency was observed in six residents who required total assistance due to various medical conditions, including paraplegia, dementia, hemiplegia, and quadriplegia. These residents were found with long fingernails, some with substances underneath, and overgrown facial hair, indicating a lack of personal hygiene care. One resident with incomplete paraplegia was observed with long fingernails and brown substances under them, despite requiring total assistance for personal hygiene. Another resident with dementia was found with long chin hairs and dirty fingernails, expressing a desire for staff assistance in grooming. Similarly, a resident with Alzheimer's disease and hemiplegia was seen with overgrown facial hair, which they could not manage independently. Additional residents with hemiplegia and quadriplegia were also noted to have unmet personal hygiene needs. One resident with a tracheostomy and contracted hands had long fingernails digging into their skin, while another with cognitive impairment and limited mobility had overgrown facial hair. The facility's Director of Nursing acknowledged the responsibility to assist residents with ADLs, yet the observations indicated a failure to meet these care requirements.
Failure to Provide Appropriate Menu Items for Special Diets
Penalty
Summary
The facility failed to meet the nutritional needs of residents on mechanical soft and pureed diets by not providing the appropriate menu items as planned. Specifically, during a lunch service, residents on mechanical soft diets did not receive the required 1 oz of gravy with their ground pork roast, resulting in a dry meal. Additionally, residents on both mechanical soft and pureed diets did not receive the soft cooked hot vegetables and pureed cooked hot vegetables, respectively, as outlined in the facility's menu spreadsheet. Instead, they were served carrots, which deviated from the planned menu. The dietary manager and cook confirmed that the gravy was not prepared, and the dietitian acknowledged that the facility should adhere to the menu spreadsheets, ensuring all residents receive the planned meals in their respective consistencies. This deficiency affected 10 residents who were on mechanical soft and pureed diets, as identified in the facility's diet order listing. The failure to provide the correct menu items as planned indicates a lapse in following dietary protocols, impacting the nutritional care of the residents involved.
Arbitration Agreement Deficiency
Penalty
Summary
The facility failed to include the required language in their arbitration agreement, indicating that signing the agreement was not a condition for admission. This deficiency affected 51 out of 176 residents who had signed the arbitration agreement. Interviews and record reviews revealed that the facility did not have a policy on arbitration, and the agreements signed before March 4, 2025, lacked the necessary verbiage. The Assistant Administrator confirmed that residents were offered arbitration agreements, but it was not mandatory for admission. However, the agreements signed before the update did not reflect this. Several residents, including those identified as R161, R171, and R148, did not recall signing the arbitration agreement or were unaware of its implications. The Corporate Admissions representative stated that the facility updated the arbitration agreement on March 4, 2025, to include the required language, but residents who signed before this date were not asked to sign the new version. This oversight led to a deficiency as the agreements signed prior to the update did not clarify that signing was not a condition for admission.
Failure to Follow Physician Orders and Assess Resident Needs
Penalty
Summary
The facility failed to adhere to physician orders for a resident, R86, who was diagnosed with hemiplegia and hemiparesis following a cerebral infarction. The physician's order required the application of an ace bandage to R86's right hand in the morning and its removal at bedtime to address swelling. However, observations revealed that the ace bandage was inconsistently applied, with R86 often found without the bandage during the day. R86 expressed discomfort and an inability to open her fingers, indicating a lack of compliance with the prescribed treatment. Staff interviews suggested a lack of clarity regarding responsibility for applying the bandage, particularly during shifts covered by agency nurses. Another resident, R100, who also had hemiplegia and hemiparesis, was not assessed for supportive devices despite having a contracted right arm and a history of stroke. R100 reported limited use of his right arm and had not been provided with any supportive devices. It was only after a surveyor's inquiry that an occupational therapist evaluated R100 and recommended a thumb spica IP free splint for optimal positioning of his thumb. The facility's failure to assess and provide necessary support for R100's condition highlights a deficiency in addressing the resident's needs for maintaining range of motion and preventing further complications.
Failure to Provide Necessary Splints and Devices for Residents with Limited ROM
Penalty
Summary
The facility failed to assess and provide necessary splints and devices to residents to maintain and prevent further reduction in range of motion (ROM). This deficiency was observed in two residents with hemiplegia and hemiparesis following cerebral infarction. The first resident, R126, had functional limitations in the left upper extremity and was observed without any splint or device to assist with ROM. Despite being cognitively intact and verbally responsive, R126 could not move his left arm and hand without assistance. It was only after prompting that the Assistant Director of Nursing requested a screening from the therapy department, which led to the recommendation of a left resting hand splint and a left upper extremity sling. Similarly, the second resident, R139, exhibited functional limitations in the right upper extremity and was also observed without any splint or device. R139, who was modified independence with cognitive skills, could not open his right hand without assistance. The Certified Nursing Assistant had to assist in opening the resident's hand. Following a prompt, the therapy department was requested to screen R139, resulting in the recommendation of a right hand roll and a right upper extremity sling. Both residents were not provided with the necessary devices until after the surveyor's intervention, indicating a lapse in the facility's protocol for addressing changes in residents' mobility and ROM needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Northlake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avenora Elmhurst | 1.7 mi | ★★★★★ | 3 | 0 |
| Grove Of Elmhurst, The | 2 mi | ★★★★★ | 3 | 0 |
| Bridgeway Senior Living | 2.7 mi | ★★★★★ | 8 | 0 |
| Gottlieb Memorial Hospital | 2.9 mi | ★★★★★ | 2 | 0 |
| Pearl Of Hillside,the | 3.1 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.