Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Care Center-wilmette during CMS and state inspections, most recent first.
The facility failed to maintain required receipt and administration documentation for controlled medications when three bottles of liquid morphine sulfate oral solution for two hospice residents were found on a unit without corresponding controlled substance requisition logs, despite the controlled drug logbook showing routine double-signature shift counts. A PRN RN confirmed that the logs were missing and began creating new forms while the surveyor was present, and later only two partially completed forms were produced, including one lacking the medication concentration. The DON reported that hospice medications from the contracted pharmacy did not arrive with logs and that logs were only created upon first use, but the hospice pharmacy’s technician stated that all controlled medications are sent with requisition logs. Subsequent review of the eMAR showed no documented administrations for these morphine orders since their most recent start dates, even though medication volumes in the bottles were not full, contrary to facility policy requiring controlled substances to be counted and documented upon delivery and at each shift change.
A resident was administered Quetiapine Fumarate for sleep and anxiety without documented justification, as the facility failed to evaluate the necessity of the medication per its policy. Observations and staff interviews indicated no behaviors or symptoms warranting its use, and the resident lacked a diagnosis supporting the medication's administration.
Failure to Maintain Required Controlled Substance Receipt and Documentation for Hospice Morphine
Penalty
Summary
The deficiency involves the facility’s failure to properly receive and document controlled medications, specifically liquid morphine sulfate oral solution prescribed for two hospice residents with multiple serious diagnoses, including hemiplegia, cerebral palsy, osteoarthritis, cervical disc degeneration, sciatica, and peripheral vascular disease. During a controlled medication observation at the sole medication cart on the second floor, a PRN RN was unable to locate controlled medication requisition logs for three liquid controlled medications: two bottles stored in the cart’s controlled box and one bottle stored in the controlled box within the medication storage refrigerator. The RN searched the cart and documents behind the nurse’s station and confirmed that the required logs were not present, stating, "we don't have it, but we should." The surveyor observed that the existing controlled medication logbook contained double signatures for shift counts, but these morphine medications were not included in that logbook. The identified morphine bottles were individually bagged, dry, and not leaking at the time of the initial observation. One bottle in the refrigerator belonged to one hospice resident and was labeled Morphine Sulfate Concentrate Oral Solution 100 mg/5 ml with 6 ml remaining; another bottle for the same resident had 15 ml remaining; and a third bottle for the second hospice resident was labeled Morphine Sulfate Concentrate Oral Solution 100 mg/5 ml with 4 ml remaining. Despite these medications being present on the unit, there were no corresponding controlled substance records in place as required by facility policy, and the RN began creating medication requisition logs in the surveyor’s presence. Later, only two newly created forms were provided to the surveyor, one for each resident’s morphine, and one of these forms did not list the medication concentration. The DON explained that controlled medications for non-hospice residents arrive from the contracted pharmacy with medication requisition logs, but stated that hospice medications from the hospice-contracted pharmacy do not come with such logs and that a requisition log is only created once the medication is taken out for use. The surveyor informed the DON that controlled medications had been found on the cart and in the storage room without corresponding logs, and the DON acknowledged this as a problem. When the DON later brought the four controlled medication bottles to the surveyors, the bottles were now wet, sticky, had rubber/plastic tops not present the prior day, and were leaking, which differed from their original observed condition. Review of the electronic MAR showed that these morphine prescriptions, including those with missing medication from the bottles, had not been documented as administered since their most recent order dates. A pharmacy technician from the hospice-contracted pharmacy stated that all controlled medications sent to facilities, including hospice medications, are supplied with medication requisition logs, and the hospice company confirmed that this was the pharmacy used. The facility’s written policy requires controlled substances to be counted upon delivery with signatures on a designated record, creation of an individual controlled substance record for each prescription, and end-of-shift controlled medication counts by oncoming and outgoing nurses with documentation of discrepancies.
Failure to Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to adhere to its policy regarding the use of psychotropic medications, resulting in a deficiency related to the unnecessary administration of such medication to a resident. The resident, an elderly female with diagnoses including difficulty in walking, lack of coordination, and osteoarthritis, was receiving Quetiapine Fumarate for sleep and anxiety. However, there was no documented evidence of a diagnosis justifying the use of this medication, such as a serious mental illness, insomnia, or anxiety. Observations and interviews with facility staff, including the Director of Nursing and a Nurse Practitioner, revealed that the resident did not exhibit behaviors or symptoms warranting the use of the antipsychotic medication. The facility's policy mandates that psychotropic medications should only be used when necessary to treat specific conditions and that residents admitted with such medications should be evaluated for their appropriateness. Despite this, the resident continued to receive the medication without a documented indication or evaluation for its necessity. The attending physician and facility staff did not identify any acute psychiatric episodes or enduring psychiatric conditions in the resident, and there was no recommendation for psychiatric evaluation. This oversight led to the resident being administered an unnecessary psychotropic medication, contrary to the facility's policy and regulatory requirements.
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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 Wilmette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Three Crowns Park | 0.9 mi | ★★★★★ | 2 | 0 |
| Westminster Place | 1.4 mi | ★★★★★ | 0 | 0 |
| Alden Estates Of Evanston | 1.5 mi | ★★★★★ | 4 | 0 |
| Pearl Of Evanston,the | 1.7 mi | ★★★★★ | 5 | 0 |
| Warren Barr Lieberman | 2 mi | ★★★★★ | 0 | 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.