Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Skokie, The during CMS and state inspections, most recent first.
Surveyors found that call lights were not accessible for five residents with varying levels of cognitive function. One resident in a wheelchair had an excessively long call light cord trapped under the wheels and could not trigger a call. Another resident in one bed had the call light placed on the adjacent bed, while a third resident’s call light was on the floor and out of reach. A fourth resident had a broken call light string that was too short to reach, and a fifth resident reported that the call light was hanging on the wall and not hooked to the bed. Staff, including an LPN, an RN, and the DON, acknowledged that call lights should be within residents’ reach, and the facility’s policy requires staff to place call lights where residents can access them.
A resident with severely impaired cognition was found in bed with a lunch tray, calling out for a spoon while her door was closed and her call light lay on the floor out of reach. The resident stated she needed a spoon and did not know where the call light was. A CNA later entered, provided a disposable spoon, and placed the call light within reach, acknowledging it should have been accessible. Review of the resident’s care plan showed she was at risk for falls and required her call light to be kept within reach and encouraged for use, and the facility’s call light policy required staff to always place the call light where residents can reach it.
A resident with dementia, Parkinson’s disease, significant weight loss, anemia, incontinence, and limited mobility was identified as at risk for pressure ulcers by Braden scoring and nutrition assessments, but no documented preventive care plan or interventions were in place before a facility-acquired right heel blister and right lateral foot stage 1 pressure injury developed. After the wounds were identified and orders were obtained for offloading devices and wound care, staff did not consistently apply heel protectors while the resident was in bed, and at least one ordered wound treatment was not documented as completed on the TAR. Staff interviews confirmed awareness of the resident’s decline in mobility and cognition and the need for assistance with repositioning and offloading, yet ordered pressure-relieving devices and prevention measures were not reliably implemented, resulting in a deficiency in pressure ulcer prevention and care.
A resident under hospice care with COPD was observed receiving continuous oxygen at 3 L/min via nasal cannula, while the physician’s order specified continuous oxygen at 1 L/min. A nurse confirmed the higher flow rate and described it as the resident’s continuous setting. Review of the facility’s oxygen policy showed it requires verification and adherence to physician orders for oxygen administration, and the DON stated nurses are expected to follow these orders and obtain new orders if changes are needed. This failure to follow the ordered oxygen flow rate and facility policy constituted a deficiency affecting one resident.
A resident admitted with urinary retention and a foley catheter had the catheter removed by facility staff without a physician's order or proper review of hospital records, despite clear discharge instructions to maintain the catheter and follow up with urology. This led to the resident developing a UTI with abnormal labs, requiring hospitalization, and the facility did not ensure timely urology follow-up.
A resident with severe cognitive impairment and a diagnosis of urinary retention was admitted with an indwelling urinary catheter, as directed by hospital discharge instructions. The ADON removed the catheter without a physician's order and without thoroughly reviewing the hospital records, which specified the need for continued catheterization and follow-up with urology. The DON later confirmed that the necessary documentation and physician order were missing, and the facility did not provide requested policies during the survey.
A resident in the dining area was verbally aggressive towards others, including yelling and cussing, without staff intervention. Despite the facility's Abuse Prevention Program, staff failed to monitor or report the incident, allowing the behavior to continue unchecked.
A facility failed to provide adequate supervision during mealtime, resulting in a resident displaying verbal aggression towards others without staff intervention. Observations and staff interviews revealed no specific schedule for monitoring the dining area, affecting three residents. The aggressive resident had a history of psychosis and anxiety, while the affected residents had various medical conditions, including schizophrenia and dementia.
A facility failed to administer medications per policy for a resident with multiple diagnoses, leaving medications unattended at the bedside. An LPN admitted to this practice, which was not in line with the facility's policy requiring monitoring during administration. Another resident reported similar issues, and the DON confirmed that neither resident was assessed for self-administration, a requirement for leaving medications at the bedside.
A resident diagnosed with Huntington's disease reported an incident involving a staff member who allegedly pushed, grabbed, and attempted to sexually assault them. The resident exhibited signs of distress and agitation following the incident. Initial assessments identified the resident as cognitively intact, but they were unable to provide detailed information immediately. Subsequent interviews and video footage identified the staff member involved. The resident's family expressed significant emotional distress over the incident. The facility initiated a comprehensive abuse investigation, including interviews and video review, but could not substantiate the sexual abuse allegation.
A resident with severe dementia and cognitive impairment managed to leave the facility unauthorized on two occasions. The first incident involved the resident being buzzed out by a visitor, resulting in a fall and hospital evaluation. The second incident occurred when the resident left unnoticed and was found disoriented by a citizen, leading to another hospital evaluation. These events highlight lapses in staff awareness, monitoring, and response to the resident's known elopement risk.
A resident experienced a 13-hour delay in receiving a STAT X-ray after a fall, resulting in the diagnosis of multiple fractures. The facility failed to follow the primary care provider's order promptly, leading to delayed diagnosis and treatment. Staff interviews revealed inconsistencies in documentation and communication regarding the urgency of the X-ray order.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure resident call lights were accessible as required by facility policy. One male resident with mild cognitive impairment was observed in his wheelchair with approximately four meters of call light string trapped under the wheelchair wheel, preventing him from triggering the call; he stated his call light was not working because the string was too long and trapped. Another female resident with severe cognitive impairment was observed lying in bed A while the call light string was located in bed B, out of her reach. A third female resident with moderate cognitive impairment was observed in bed with her call light on the floor, and she stated she could not access it. A fourth female resident with intact cognition was observed in her room with a broken call light string on the wall that was only about one foot long and could not reach her. A fifth female resident with intact cognition was observed in bed with a call light hanging from the wall; she stated that her call light was not hooked up to her bed so she could not use it to call. Staff interviewed, including an LPN, an RN, and the DON, acknowledged that call lights should be accessible to residents so they can call for help. The facility’s undated call light policy stated that staff are to place the call light where the resident can reach it, but observations showed this was not consistently done for the five residents reviewed.
Failure to Keep Call Light Within Reach for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its call light policy and a resident’s care plan requirement to keep the call light within reach so needs could be promptly identified and met. A female resident with severely impaired cognition, as documented on the MDS, was observed in bed with her lunch tray while her door was closed and her call light was on the floor, out of her reach. The surveyor heard the resident screaming from the hallway for a spoon to eat her lunch and, upon entering the room, the resident stated she needed a spoon and did not know where her call light was. Shortly thereafter, a CNA entered, provided a disposable spoon, retrieved the call light from the floor, and placed it within the resident’s reach, acknowledging that the call light should be accessible and expressing uncertainty about why it was not. Review of the resident’s care plan showed she was care planned for risk of falls with interventions that included ensuring the call light was within reach and encouraging its use for assistance, and the facility’s written call light policy required staff to place the call light where the resident could always reach it. These observations, interviews, and record reviews demonstrate that the resident’s call light was not maintained within reach as required by both her individualized care plan and the facility’s call light policy, resulting in the resident having to call out verbally for assistance instead of using the call light system.
Failure to Implement and Follow Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement timely and appropriate pressure ulcer prevention interventions for a resident with dementia, Parkinson’s disease, significant weight loss, and documented risk for skin breakdown, and failure to consistently apply ordered pressure reduction devices after pressure injuries developed. The resident had a Braden Scale score of 15 on 10/2/25, indicating risk for pressure ulcers, with documented factors including very moist skin, very limited mobility, slightly limited sensation, adequate nutrition, and friction/shear as a potential problem. A nutrition note dated 10/15/25 documented a 17.33% significant weight loss over six months, mild anemia, risk for poor nutrition, and explicitly identified the resident as a skin breakdown risk with a goal to prevent further weight loss and skin breakdown. Despite these findings, there was no documentation of any care plan or preventive interventions implemented before the development of the right heel blister and right lateral foot stage 1 pressure injury. On 11/10/25, during a skin check, staff identified a blister on the right heel and a skin alteration on the right lateral foot, later classified as a facility-acquired right heel blister and a stage 1 pressure ulcer on the right lateral foot. A Braden Scale completed the same day showed a score of 14, indicating moderate risk, with the resident’s activity level changed to chairfast. The resident’s MDS documented severe cognitive impairment, wheelchair use, need for supervision/touching assistance with bed mobility, partial/moderate assistance with transfers, and risk for pressure ulcers, with recommended treatments including pressure-reducing devices for chair and bed. However, the care plan dated 11/10/25 only addressed actual skin breakdown after the wounds were identified, with interventions such as protecting heels and providing new soft shoes, and there was no evidence of a prior preventive care plan or interventions despite the earlier Braden and nutrition findings. After the wounds developed, the physician ordered offloading devices on the feet while in bed every shift for wound prevention on 11/13/25, and wound care treatments were ordered on 11/10/25. Staff interviews and observations showed that these interventions were not consistently implemented. On 11/20/25, the resident was observed in bed without heel protectors, despite CNA and nursing staff stating that heel protectors should be on at all times while the resident is in bed. The private caregiver at the bedside reported not applying the heel protectors because they were too hard to put on and acknowledged the resident’s recent mental decline, decreased mobility, and need for assistance with repositioning. The wound care coordinator and nurse practitioner both identified multiple risk factors for wound development, including dementia progression, decreased mobility, incontinence, muscle weakness, and poor or at-risk nutrition, and indicated that interventions such as heel protectors, offloading, turning, and incontinence care were needed. Additionally, the Treatment Administration Record for 11/2025 showed that ordered wound care treatments to the right heel and right lateral foot were not documented as completed on 11/19/25, and the facility’s pressure ulcer prevention policy required risk assessment on admission, weekly, and upon changes in condition, and selection of appropriate support surfaces based on risk factors, which were not fully carried out for this resident prior to and after wound development. The facility’s own documentation further reflected gaps in assessing and documenting the unavoidability of the wounds. A Pressure Ulcer Unavoidability Screen dated 11/11/25 noted the presence of the right lateral foot pressure ulcer and right heel blister, the resident’s daily chair use, caregiver presence, and weight changes with dietitian follow-up, but did not include a score or statements explaining why the wounds were considered unavoidable. Interviews with staff indicated that the resident had a recent progression in dementia and overall decline over approximately two weeks, with decreased movement in bed and increased need for assistance with ADLs and repositioning, yet the wound care coordinator acknowledged that no heel protector order was in place before the wounds developed and that the focus had been on dietary interventions rather than additional skin and pressure prevention measures. At the time of surveyor review, there was also no evidence of updated laboratory evaluations following the resident’s decline, despite recognition that poor nutrition and anemia contributed to wound risk. The facility’s prevention policy required review of the care plan, identification of risk factors, and implementation of interventions to reduce or eliminate modifiable risks, including appropriate support surfaces and repositioning frequency based on mobility, skin condition, and other factors. In this case, the resident’s documented risk factors—dementia, Parkinson’s disease, incontinence, chairfast status, significant weight loss, anemia, and Braden scores indicating risk and then moderate risk—were known prior to the development of the right heel blister and right lateral foot stage 1 pressure injury, but there was no documented preventive care plan or interventions in place before the wounds occurred. After the wounds developed and orders for offloading devices and wound treatments were obtained, staff did not consistently ensure that heel protectors were applied while the resident was in bed, and at least one day’s wound treatment was not documented as completed on the TAR, contributing to the cited deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Follow Physician Order for Oxygen Administration
Penalty
Summary
Surveyors identified that the facility failed to follow its oxygen administration policy and the physician’s order for a hospice resident receiving oxygen therapy. On 11/18/25 at 10:15 AM, the resident was observed in bed with an oxygen concentrator at the bedside set at 3 L/min via nasal cannula. At 11:00 AM the same day, a nurse confirmed that the oxygen setting was 3 L/min and stated that the resident was on continuous oxygen at that rate. Record review showed a physician’s order, effective 9/5/25, for continuous oxygen at 1 L/min via nasal cannula. The resident is an adult male under hospice care with a diagnosis of COPD that began on 7/18/25. The DON stated that nurses are expected to follow physician orders for oxygen administration and to call the attending physician for an order if oxygen needs to be increased. The facility’s Oxygen Administration Policy, revised October 2010, requires verification of a physician’s order and review of the order or facility protocol for oxygen administration, which was not followed in this case. This deficient practice affected one resident out of three reviewed for oxygen administration in a total sample of 23 residents.
Failure to Obtain Physician Order for Catheter Removal and Inadequate Review of Hospital Records
Penalty
Summary
The facility failed to obtain a physician's order prior to removing an indwelling urinary catheter from a resident who was admitted with a diagnosis of urinary retention. Upon admission, the resident had a foley catheter in place as documented in the hospital records, with clear instructions for follow-up with urology and a recommendation to maintain the catheter due to urinary retention. The resident's hospital discharge summary and transition of care documents specified the need for continued catheterization and prompt outpatient urology follow-up. Despite these instructions, the Assistant Director of Nursing removed the resident's urinary catheter, documenting that there was no qualifying diagnosis, without a physician's order or documented consultation with the resident's physician or nurse practitioner. The Director of Nursing later acknowledged that the hospital documents supporting the need for the catheter were missed during the review process and that the removal should not have occurred without a physician's order. There was no documentation that the facility notified the urologist or the resident's physician about the catheter removal. Following the removal of the catheter, the resident developed abnormal laboratory values, including a significantly elevated BUN, and was diagnosed with a urinary tract infection caused by resistant bacteria. The resident required hospitalization, where a large volume of purulent urine was drained after re-insertion of a foley catheter. The facility also failed to ensure timely urology follow-up as directed in the hospital discharge instructions. The facility was unable to provide requested policies during the survey.
Failure to Obtain Physician Order and Review Hospital Records Prior to Catheter Removal
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of urinary retention was admitted to the facility with an indwelling urinary catheter, as documented in hospital discharge records and transition of care forms. The resident's hospital records specified that the catheter was to remain in place, with follow-up care by a urologist recommended. Despite these instructions, the Assistant Director of Nursing (ADON) removed the resident's urinary catheter without obtaining a physician's order or thoroughly reviewing the hospital discharge documents. The physician order sheets did not contain any order to discontinue the catheter, and there was no documentation that the resident's physician was notified of the catheter removal. The Director of Nursing (DON) later acknowledged that the hospital documents indicating the need for the catheter were missed and that a physician's order should have been obtained prior to removal. The facility also failed to document the resident's urinary retention diagnosis from the transition of care forms and did not provide requested facility policies during the survey. These actions and omissions resulted in the facility not providing care and services according to accepted professional standards of practice for one resident reviewed for improper nursing care.
Failure to Prevent Verbal Abuse in Dining Area
Penalty
Summary
The facility failed to protect residents from verbal abuse, as evidenced by the behavior of a resident identified as R93, who was verbally aggressive towards other residents in the dining area. During observations on two consecutive days, R93 was seen yelling, cussing, and making hand gestures at fellow residents, including R6, R25, and R53, without any intervention from the staff. The staff were intermittently present in the dining room and did not monitor or redirect R93's aggressive behavior. This lack of supervision and intervention allowed the verbal abuse to continue unchecked. The facility's Abuse Prevention Program mandates staff training on abuse prevention, identification, and reporting, yet the staff failed to report the verbal abuse incident to the Administrator/Abuse Prevention Coordinator, V1. V1 was unaware of the incident until informed by the surveyor. The program requires staff to separate residents involved in verbal abuse and provide monitoring, but these steps were not taken. The deficiency highlights a failure in the facility's abuse prevention and reporting protocols, as staff did not follow the established procedures to protect residents from abuse.
Lack of Supervision During Mealtime Leads to Verbal Aggression
Penalty
Summary
The facility failed to provide consistent monitoring and supervision for a verbally aggressive resident during lunchtime in the second-floor dining room. This deficiency affected three residents who were subjected to verbal aggression from another resident without staff intervention. Observations revealed that during the lunchtime meal service, no staff were present to monitor or redirect the aggressive behavior of the resident, who was yelling and making hand gestures towards others. Interviews with various staff members, including a CNA, Activities Director, LPN, Assistant Director of Nursing, and Director of Nursing, confirmed that there was no specific schedule or assignment for staff to monitor the dining area during mealtimes. The affected residents included a male with diagnoses such as Type 2 Diabetes Mellitus, Paranoid Schizophrenia, and Major Depressive Disorder; a female with Chronic Obstructive Pulmonary Disease and Schizoaffective Disorder; and another female with Unspecified Dementia and Vascular Dementia. The aggressive resident had a history of Unspecified Psychosis and Anxiety Disorder. The facility's policy on safety and supervision emphasized an individualized, resident-centered approach, but the lack of a structured monitoring system during mealtimes led to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications according to its policy for a resident, identified as R40, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, Bipolar Disorder, and Schizophrenia. During a medication administration observation, an LPN left a medication cup containing 15 scheduled medications at the resident's bedside, contrary to the facility's policy which requires nurses to remain with the resident until the medication is swallowed. The LPN admitted to leaving the medications unattended and was unsure if the resident took any of them. Additionally, another resident, R84, reported that medications were left at her bedside and that she was instructed to return to her room due to the presence of surveyors. The LPN confirmed this practice, acknowledging that it was not appropriate and that the resident should have been monitored during medication administration. The facility's Director of Nursing stated that neither resident had been assessed for self-administration of medications, which is a requirement for leaving medications at the bedside. The facility's policy mandates that medications be administered in accordance with physician orders and that any deviations, such as withholding or delaying doses, be documented in the Medication Administration Record (MAR). The LPN's actions did not comply with these requirements, as there was no documentation of whether R40's medications were administered or withheld. The facility's policy also requires checking vital signs before administering high blood pressure medications, which the LPN initially held due to low blood pressure readings but later administered without confirming if the resident took the other medications.
Incident of Staff to Resident Sexual Assault and Inappropriate Exposure
Penalty
Summary
The facility failed to prevent an incident of staff to resident sexual assault and inappropriate exposure, affecting one resident (R1) diagnosed with Huntington's disease. R1, who was initially assessed as cognitively intact, exhibited signs of distress and agitation following the incident. R1 reported being forcibly pushed down, grabbed, and exposed to attempted rape by a staff member (V6). Despite R1's inability to provide detailed information initially, subsequent interviews and video footage identified V6 as the alleged perpetrator. R1's family expressed deep emotional distress over the incident, highlighting the significant impact on both the resident and their loved ones. The facility's response to the incident included immediate actions such as initiating a comprehensive abuse investigation, notifying the police, and providing one-to-one supervision for R1's safety. The investigation involved interviews with facility employees and residents, review of video footage, and assessment of R1's statements. While the investigation could not substantiate the sexual abuse allegation, the facility took steps to suspend and reinstate the employee pending investigation results. The incident prompted the facility to conduct education sessions on abuse and neglect policies, emphasizing reporting procedures and ensuring all employees received training on these critical issues.
Supervision and Safety Measures Deficiency Leading to Resident Elopement
Penalty
Summary
The report highlights a significant deficiency in the facility's supervision and safety measures, particularly regarding the prevention of elopement by a resident identified as R1. R1, diagnosed with unspecified severe dementia and exhibiting cognitive impairment, managed to leave the facility unauthorized on two separate occasions. The first incident occurred on 01/05/24 when R1 was buzzed out by a visitor, leading to a fall outside the facility and subsequent hospital evaluation. The second incident took place on 03/11/24 when R1 left the facility unnoticed, was found disoriented by a concerned citizen, and taken to the hospital for evaluation. Despite R1's known elopement risk and cognitive impairment, the facility failed to effectively monitor and prevent these occurrences. The facility's failure to prevent R1's unauthorized exits raises concerns about the adequacy of their supervision protocols and safety measures. Despite R1's documented history of dementia, impaired decision-making skills, and a known risk for elopement, the facility did not have sufficient systems in place to ensure R1's safety and prevent unauthorized departures. The incidents on 01/05/24 and 03/11/24 highlight lapses in staff awareness, monitoring, and response to R1's elopement risk, ultimately resulting in R1 leaving the facility unattended and being found disoriented outside.
Failure to Follow STAT X-ray Order After Resident Fall
Penalty
Summary
The facility failed to follow the primary care provider's order to conduct a STAT X-ray after a resident (R4) experienced a fall. This resulted in a 13-hour delay in obtaining the X-ray, which subsequently revealed five right-side rib fractures and an acute fracture of the right elbow. The incident report noted that R4 fell in the front lobby while attempting to go outside for fresh air, despite being advised against it due to weather conditions. The resident lost balance and fell, landing on his right hand and bottom. Initial assessments showed the resident was alert and oriented, with a pain level of 6, and the primary care provider was notified, who then ordered a STAT X-ray for the right elbow and ribs due to the resident's complaints of pain. Despite the physician's order for a STAT X-ray, the facility did not immediately process the order. The X-ray was not conducted until the following day, resulting in a significant delay. The resident continued to complain of severe pain, and the X-ray results, received later, confirmed multiple fractures. The delay in obtaining the X-ray and subsequent diagnosis led to the resident being sent to the hospital for further management. Interviews with the staff revealed inconsistencies in the documentation and communication regarding the urgency of the X-ray order. The Director of Nursing (DON) and other staff members acknowledged the delay and the failure to follow the STAT order protocol. The radiology company confirmed that the initial order was received as a routine order and was later upgraded to STAT. The facility's policy requires that STAT orders be processed immediately, but this was not adhered to in this case. The failure to promptly execute the STAT X-ray order resulted in delayed diagnosis and treatment for the resident's injuries.
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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 Skokie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warren Barr Lieberman | 0.3 mi | ★★★★★ | 0 | 0 |
| Alden Estates Of Skokie | 0.5 mi | ★★★★★ | 6 | 0 |
| Alden Estates Of Evanston | 0.8 mi | ★★★★★ | 4 | 0 |
| Grove Of Skokie, The | 0.9 mi | ★★★★★ | 1 | 0 |
| Westminster Place | 1 mi | ★★★★★ | 0 | 0 |
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