Citadel Care Center-Wilmette

In the surveyor’s words

From the most serious findings on record at Citadel Care Center-Wilmette, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 5, 2023

  Based in interview and record review, the facility failed to develop an effective fall intervention to include monitoring and supervision for a resident assessed to be high risk for falls, has history of falls, has poor safety awareness, and has impulsive behaviors. This affected 1 of 3 residents (R1) reviewed for falls and fall prevention. This failure resulted in R1 getting up unsupervised, falling to the floor which resulted in a forehead laceration which required sutures. Findings include: On 3-31-23 at 10:05 AM, R1 is primarily Spanish speaking and translator was needed. […]

• No harm, potential for more than minimal, isolatedF755Apr 9, 2026

  Based on observation, interview, and record review, the facility failed to ensure that the residents' controlled medications were properly received and documented on according to facility policy by failing to: 1. Maintain documentation of receiving controlled medications, upon receipt of medication into the facility and maintaining administration information for controlled medications; this deficient practice affected two (R1 and R8) of two residents. This deficient practice affected two (R1 and R8) of two residents reviewed for controlled medication management in the sample of 60 and has the potential to affect all residents prescribed controlled medications in the facility.Findings:R1 is an [AGE] year-old resident, on hospice care, with diagnoses of, but not limited to hemiplegia,… […]

• No harm, potential for more than minimal, isolatedF758Feb 20, 2025

  Based on interview and record review, the facility failed to follow their policy related to psychotropic medications and ensure one resident (R49) was free from unnecessary psychotropic medications. Findings Include: R49 is an [AGE] year-old female who admitted to the facility on [DATE] and continues to reside in the facility. R49 has multiple diagnoses including but not limited to the following: difficulty in walking, lack of coordination, and osteoarthritis. Per physician orders resident is receiving Quetiapine Fumarate Oral Tablet 25 mg - Give 0.5 tablet by mouth at bedtime for sleep/anxiety. On 2/19/2025 at 12:25PM, R49 was noted to be calm and alert and oriented with no behaviors. […]

• No harm, potential for more than minimal, isolatedF689Dec 11, 2023

  Based on observation, interview, and record review, the facility failed to safely transfer a resident (R1) with a mechanical lift. This applies to 1 of 3 residents reviewed for safety & supervision in the sample of 4. The findings include: R1's electronic face sheet showed R1 has diagnoses including but not limited to urinary tract infection, morbid obesity, acute pulmonary edema, and heart failure. R1's facility assessment dated [DATE] showed R1 has no cognitive impairment and is dependent on staff for all transfers. R1's weight documented 12/6/23 showed R1 weighs 363.4lbs. […]

• No harm, potential for more than minimal, isolatedF690Dec 11, 2023

  Based on observation, interview, and record review, the facility failed to perform incontinence care and provide catheter care in a manner to prevent urinary tract infections for 1 resident. The facility also failed to position a resident's urinary catheter bag off the floor for 1 resident. These failures apply to 2 of 3 residents (R1, R2) reviewed for incontinence care in the sample of 4. The findings include: 1) R1's electronic face sheet showed R1 has diagnoses including but not limited to urinary tract infection, morbid obesity, acute pulmonary edema, and heart failure. R1's facility assessment dated [DATE] showed R1 has no cognitive impairment and is occasionally incontinent of bladder. […]