Citadel of Northbrook, The

In the surveyor’s words

From the most serious findings on record at Citadel of Northbrook, The, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 11, 2025

  Based on interview and record review, the facility failed to meet a resident's need to have two staff assist while being provided incontinence care per the resident's assessed needs. This failure applied to one (R38) of three residents reviewed for falls and resulted in R38 sustaining a fall while being provided incontinence care that resulted in fractures to the right fourth and fifth ribs and a 6.5-centimeter infrapatellar subcutaneous hematoma to the right knee.Findings include:R38 is a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses including but not limited to obesity, heart failure, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, chronic obstructive pulmonary disease, and seizures.On the (MDS) Minimal Data Set… […]

• Actual harm, isolatedF689May 17, 2024

  Based on interviews and record reviews, the facility failed to provide effective supervision to prevent an avoidable fall for one resident (R1) exhibiting increased confusion/agitation/wandering due to dementia and low blood sugar levels. This affected one of three residents (R1) reviewed for fall prevention. This failure resulted in R1 being involved in a fall incident sustaining a right femur fracture. Findings include: R1's medical record notes R1 with diagnoses including, but not limited to, diabetes, unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, and weakness. R1's MDS (minimum data set), dated 3/14/24, notes R1's BIMS (brief interview of mental status) score was 5 out of 15. R1 required partial assistance with bed mobility. […]

• Actual harm, isolatedF689Jan 27, 2024

  Based on interview and record review, the facility failed to provide safe transfer with a full (mechanical) lift per care plan; failed to inform doctor of refusal in using the (mechanical) lift and failed to reassess for safe transfers for 1 (R1) of three residents (R1, R2, R3) reviewed for falls. This failure resulted to R1 sliding on the floor sustaining a fracture of the tibia/fibula. Findings include: R1's Facesheet indicates that R1 was admitted to the facility on [DATE] with diagnosis including but not limited to: Chronic Obstructive Pulmonary Disease, Emphysema, Chronic Respiratory Failure with Hypoxia and Hypercapnia, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Nondisplaced Oblique Fracture of the Shaft of Right Tibia, Venous Thrombosis and Embolism, Disorder of the… […]

• Actual harm, isolatedF600Aug 21, 2023

  Based on interview and record review, the facility failed to prevent or identify the origin of how a resident sustained a right hip fracture. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 complaining of pain to the right leg. R1 was assessed, sent to the local hospital, and diagnosed and treated for complex comminuted periprosthetic fracture. Findings include: R1 face sheet shows R1 is [AGE] year-old female, R1 has diagnoses of presence of right artificial hip joint, history of falling, unspecified dementia, lack of coordination. […]

• Actual harm, isolatedF686Jan 20, 2023

  Based on observation, interview and record review, the facility has the following failures for 3 out of 6 residents (R6, R25 and R91) for a total sample of 30 residents reviewed for pressure ulcers: Failed to follow their wound prevention and management policy to ensure residents does not develop pressure ulcers. Failed ensure that residents received wound treatments. Failed to follow manufacture's instruction for proper settings on the low air mattress. Failed to maintain correct dressing per physician's order. Failed to monitor skin status for prevention of pressure ulcers. Failed to refer residents with new and worsening pressure ulcers to wound care physician for assessment and treatment. […]