Above 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 Of Northbrook, The during CMS and state inspections, most recent first.
A CNA was observed feeding a resident while standing over them, contrary to the facility's policy requiring staff to sit at eye level to maintain dignity. The CNA claimed no chair was available, but the Unit Manager confirmed chairs were present. The DON emphasized the importance of sitting while feeding to ensure resident dignity.
A resident was observed self-administering eye drops without a physician's order or an assessment by the IDT, contrary to the facility's policy. The resident, who is alert and oriented, had been using the medication at her bedside without proper documentation or a care plan. The facility's policy requires a physician's order, an assessment of the resident's abilities, and secure storage of medications, none of which were followed in this case.
A facility failed to follow manufacturer recommendations for a low air loss mattress by using multilayers of linen for a resident with stage 4 pressure ulcers. Despite instructions to use only a flat sheet, observations showed additional linens were used, potentially affecting wound care management. The facility lacked a specific policy on LAL mattress use.
A facility failed to identify and address a resident's change in left-hand range of motion, resulting in a deficiency. The resident was observed with a left-hand flexion contraction without a hand splint, which was not previously noted by the Restorative Nurse. The issue was only reported after a surveyor's observation, and the resident was subsequently referred to occupational therapy for evaluation.
The facility failed to follow proper infection control practices during feeding assistance. A nurse fed multiple residents without hand hygiene, and a CNA did not use appropriate PPE for a resident on Enhanced Barrier Precaution. Another CNA distributed meal trays and assisted residents without sanitizing hands between tasks. The DON confirmed the expectations for hand hygiene and PPE use.
The facility did not post [NAME] program information in accessible locations for 77 eligible residents. The administrator claimed postings were in all units, but observations showed they were missing from key areas. Only one posting was found by the nursing station on the second floor, contrary to the facility's policy requiring conspicuous display of program information.
A resident with severe cognitive impairment and low blood sugar levels fell and fractured her right femur due to inadequate supervision and the absence of her walker. The resident was more confused than usual and wandered away from her room, leading to the fall. Staff failed to communicate the resident's increased confusion and did not provide necessary mobility aids.
The facility failed to follow physician's orders and administer medication properly for nine residents. An LPN returned a metoprolol tablet to the blister pack with unclean hands and did not sign out medications immediately. A resident was found with old medications at her bedside, indicating a lapse in proper medication administration and documentation.
The facility failed to maintain a medication error rate of 5% or less, resulting in a 38.24% error rate. An LPN administered incorrect and omitted medications for two residents, including heart medication digoxin and several other prescribed drugs. The facility's medication administration policy was not followed.
The facility failed to follow hand hygiene procedures during medication administration for two residents. An LPN was observed preparing and administering medications without performing hand hygiene, touching common surfaces, and continuing this practice for both residents. The facility's policy requires thorough hand hygiene before and during medication administration, which was not followed.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to provide dignity to a resident during feeding, as observed on February 18, 2025. A Certified Nurse Aide (CNA) was seen feeding a resident while standing over them in the dining room, despite acknowledging the need to be seated while assisting with meals. The CNA claimed there was no chair available, although the Unit Manager confirmed that chairs were indeed available in the dining room. The Director of Nursing reiterated that staff should sit next to residents to maintain eye level and dignity during feeding, in accordance with the facility's policy on Assistance with Meals, which emphasizes feeding residents with attention to safety, comfort, and dignity. The facility's policy on Residents Rights also mandates treating all residents with kindness, respect, and dignity.
Failure to Implement Self-Administration Policy for Resident Medications
Penalty
Summary
The facility failed to adhere to its policy on resident self-administration of medications, affecting one resident in a sample of 26. The resident, who is alert and oriented, was observed using eye drops at her bedside without a physician's order or an assessment by the Interdisciplinary Team (IDT) to determine the safety and appropriateness of self-administration. The eye drops were not labeled, and there was no documentation or care plan in place for the resident's self-administration of medication. The Registered Nurse (RN) acknowledged awareness of the resident's self-administration but did not document it, and there was no physician order present in the resident's medication administration record. The facility's policy requires an assessment of the resident's mental and physical abilities by the staff and practitioner to determine if self-administration is clinically appropriate. Additionally, a physician's order and a specific skills assessment are necessary, including the resident's ability to read medication labels, understand dosage, and recognize risks. The policy also mandates that self-administered medications be stored securely, which was not ensured in this case. The Director of Nursing (DON) confirmed that these steps were not followed, leading to the deficiency.
Improper Use of Low Air Loss Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to the manufacturer's recommendations for the use of a low air loss (LAL) mattress for a resident with stage 4 pressure ulcers. During observations, it was noted that the resident was lying on a LAL mattress with a flat sheet and a folded linen, contrary to the requirement of using only a flat sheet. The Director of Nursing confirmed that the resident should only have a flat sheet over the LAL mattress. Despite this, subsequent observations showed the continued use of additional linen layers over the mattress. The resident in question was admitted with diagnoses including a stage 3 pressure ulcer on the right upper back and a stage 4 pressure ulcer on the sacral region. The facility's active physician order sheet outlined specific wound care procedures for these ulcers. However, the facility did not provide a policy on the use of LAL mattresses, and the existing policy on support surface guidelines did not address the specific issue of multilayer linen use. This oversight in following proper mattress usage protocol potentially compromised the resident's wound care management.
Failure to Identify and Address Change in Range of Motion
Penalty
Summary
The facility failed to ensure ongoing assessment and identification of changes in a resident's left-hand range of motion, leading to a deficiency in care. During an observation, it was noted that the resident had a left-hand flexion contraction without a hand splint applied, which was confirmed by the Restorative CNA and LPN. The Restorative Nurse had previously assessed the resident and did not observe any limitations in range of motion at that time. However, the decrease in the resident's left-hand range of motion was only reported after the surveyor's observation. The Director of Nursing stated that the expectation is for restorative staff to report any changes in range of motion to the nurse for appropriate referral and treatment. The Occupational Therapist evaluated the resident following the referral and noted impairments in the upper extremity range of motion and strength. The facility's policy requires staff and physicians to identify individuals with potential for significant improvement or decline in function, including the ability to perform activities of daily living, which was not adhered to in this case.
Infection Control Lapses During Feeding Assistance
Penalty
Summary
The facility failed to adhere to proper infection control practices during feeding assistance, as observed in multiple instances. A Registered Nurse (RN) was seen feeding one resident and then another without performing hand hygiene in between. The RN acknowledged the lapse in protocol, admitting that she did not wash her hands after feeding one resident before moving to another. The Unit Manager confirmed that all staff should perform hand hygiene before and after assisting with feeding, and the Director of Nursing (DON) reiterated the expectation for staff to perform hand hygiene before and after feeding residents and when touching surfaces. Additionally, a Certified Nurse Assistant (CNA) was observed feeding a resident on Enhanced Barrier Precaution (EBP) while only wearing gloves, with her clothes touching the side rails of the bed. The CNA believed gloves were sufficient since she was only feeding, but a Registered Nurse and the DON clarified that additional Personal Protective Equipment (PPE), such as a gown and mask, should be worn due to direct contact with the resident. Another CNA was seen distributing lunch trays and assisting residents without using hand sanitizer or washing hands between tasks. The DON stated that a nurse, CNA, and restorative aid should be present during meals, and all employees are expected to wash hands between touching residents and sanitize between tasks.
Failure to Post [NAME] Program Information
Penalty
Summary
The facility failed to post information about the [NAME] program in an accessible and visible location for residents, affecting 77 residents eligible for the program. During an observation on 2/18/25, the administrator, V1, stated that the program information was posted in all three units and that social services were responsible for the program, while she was responsible for ensuring the postings were visible to all residents. However, during rounds with V1, no postings were found at the front desk/front lobby or in the Medbridge and Arcadia units on the first floor. A posting was only found by the nursing station of the Brookview unit on the second floor. On 2/19/25, V1 confirmed that 77 out of 132 residents in the facility were eligible for the [NAME] program. The facility's policy requires educational materials and information to be provided to newly admitted members and for a poster to be conspicuously displayed, informing residents of their rights and services under the [NAME] Consent Decree.
Failure to Prevent Avoidable Fall
Penalty
Summary
The facility failed to provide effective supervision to prevent an avoidable fall for a resident exhibiting increased confusion, agitation, and wandering due to dementia and low blood sugar levels. The resident, who had severe cognitive impairment and required substantial assistance with mobility, was found on the floor with a right femur fracture after wandering away from her room. The resident's care plan noted a high risk for falls, and physical therapy records indicated the need for a walker and verbal cues for safe ambulation. On the day of the incident, the resident was more confused than usual and was looking for her brother. Despite this, the resident was left unsupervised and without her walker. A CNA found the resident on the floor, and a subsequent assessment revealed a right femur fracture. The resident's blood sugar was critically low, which likely contributed to her increased confusion and agitation. Staff interviews revealed that the resident's increased confusion and wandering behavior were not adequately communicated during shift changes. Additionally, the resident's walker was not present at the time of the fall, and staff were not paying attention to the resident's whereabouts. The lack of supervision and failure to provide necessary mobility aids directly led to the resident's fall and subsequent injury.
Failure in Medication Administration and Documentation
Penalty
Summary
The facility failed to follow physician's orders and administer medication in accordance with acceptable clinical practice for nine residents. An LPN was observed returning a metoprolol tablet to the medication blister pack with unclean hands after it fell out of the medication cup onto a tray. The LPN admitted to not signing out all medications as given on the MAR, often completing documentation after finishing the medication pass. The Director of Nursing confirmed that medications should be documented immediately after administration and discarded if not administered. The facility's policy supports this practice, stating that medications must be recorded directly after administration and not left unrecorded or unsigned before the end of the shift. Additionally, a resident was found with a medication cup containing four large white pills on her bedside table, which she believed might be from the previous day. The Unit Manager identified the medications and confirmed that it is not normal practice to leave medications at the bedside. The resident reported not receiving her medication on time and noticing small flies in her room. This incident highlights a failure in medication administration and documentation, as well as a lapse in ensuring the resident's environment was clean and free of pests.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 38.24% error rate for one resident. During the administration of 9:00 AM medications, the LPN was observed administering medications to a resident who only wanted one pill. The LPN acknowledged this but proceeded to administer two pills in applesauce, one of which was spit out by the resident. The LPN did not re-offer the medication or identify it until prompted by the surveyor, revealing it to be digoxin, a heart medication. Further reconciliation against the Medication Administration Records (MAR) revealed multiple errors, including incorrect dosages and omitted medications such as Loratadine, Fluticasone Propionate, and Diclofenac Sodium Gel. Additional errors were observed when the LPN administered medications to another resident. The LPN gave incorrect medications, such as vitamin B12 instead of Cholecalciferol and Senna Plus instead of separate doses of Docusate Sodium and Sennosides. The LPN also held Metoprolol Tartrate without notifying the physician and omitted several other medications, including Lexapro, Spiriva HandiHaler, Artificial Tears, Keppra, and NasoGel. The facility's policy on medication administration, which includes the 'Five Rights' and triple-check procedures, was not followed, leading to these deficiencies.
Failure to Follow Hand Hygiene Procedures During Medication Administration
Penalty
Summary
The facility failed to follow hand hygiene procedures during medication administration for two residents, R23 and R45. On 4/9/24 at 9:14 AM, an LPN was observed preparing and administering medications without performing hand hygiene at the beginning of the observation. The LPN removed tablets from medication blister cards by popping the medications into their hand and placing them into medication cups. As the LPN moved across the cart, touching cards and common surfaces, they did not stop to perform hand hygiene. This practice continued for both residents. The facility's policy on medication administration, revised in 10/2014, states that hand hygiene should be performed thoroughly before beginning a medication pass, prior to handling any medication, and after coming into direct contact with a resident, among other specific instances. The LPN did not adhere to these guidelines during the observed medication administration process.
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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 Northbrook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elevate Care Abington | 1.9 mi | ★★★★★ | 1 | 0 |
| Brandel Health And Rehab | 2 mi | ★★★★★ | 1 | 0 |
| Glenview Terrace | 2.2 mi | ★★★★★ | 4 | 1 |
| Eden Vista Prospect Heights | 2.4 mi | ★★★★★ | 8 | 0 |
| Ascension Nazarethville Place | 2.6 mi | ★★★★★ | 3 | 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.