Citadel of Skokie, The

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Apr 26, 2024

  Based on interview and a record review, the facility failed to prevent an incident of staff to resident sexual assault and inappropriate exposure. This affected one of three residents (R1) reviewed for sexual assault and inappropriate exposure. This failure resulted in V6 forcibly pushing R1 down onto her back, grabbing her breast, undoing his clothing and exposed his penis to attempting to rape R1. R1 said, she felt hurt and wished for death. R1 said, she felt victimized, traumatized, and feared for her safety. The Immediate Jeopardy began on 04/09/24 when V6 exposed his penis and sexually assaulted R1. V1 (Administrator), V2 (Director of Nursing) and V14 (Chief Operating Officer) was notified of the Immediate Jeopardy on 04/18/24 at 11:40AM. […]

• Immediate jeopardy, isolatedF689Apr 5, 2024

  Based on interview and record review the facility failed to have effective system in place to prevent a resident from leaving the facility unauthorized on two different occasions. This affected one of three residents (R1) reviewed for supervision and elopement. This failure resulted in R1 being buzzed out of the facility with a visitor without staff knowledge on 01/05/24, and R1 able to leave the facility without staff knowledge on 03/11/24 after a staff member failed to ensure the door was closed securely after entering. […]

• Actual harm, isolatedF690Apr 17, 2025

  Based on interview and record review, the facility failed to obtain a physician's order to remove an indwelling urinary catheter for a resident diagnosed with urinary retention and failed to review a resident's hospital records upon admission for the diagnosis and follow up care for the indwelling urinary catheter. These failures affected one (R1) of four residents reviewed for improper nursing care. This failure resulted in R1 developing abnormal lab values with urinary retention and UTI (Urinary Tract Infection), subsequently requiring hospitalization . Findings include: R1 is [AGE] years of age. […]

• Actual harm, isolatedF684Apr 5, 2024

  Based on interview and record review the facility failed to follow the order of the primary care provider by not ordering a STAT Xray after a fall incident. This affected one of three residents (R4) reviewed for following the physician orders. This failure resulted in a 13-hour delay in R4 having an Xray conducted subsequently resulting in a diagnosis of 5 right side rib fractures and an acute fracture of right elbow. Findings include: R4 care plan shows diagnosis of intervertebral disc degeneration lumbar region, bipolar disorder, history of falling, pain in the right elbow, repeated falls, fracture of one rib left side, multiple fracture of ribs right side an issue for close fracture, multiple fracture of ribs left side initial encounter for closed fracture, displaced fracture of right… […]

• Actual harm, isolatedF684Mar 1, 2023

  Based on observations, interviews, and record review, this facility failed to identify an emergent situation and immediately activate the 911 system. This affected 1 of 3 residents (R1) reviewed for activating 911 in an acute change in condition. This failure resulted in a 30-minute delay in 911 being called and R1 being transported to the local hospital for emergent treatment. Findings include: On [DATE] at 11:45am, this surveyor observed R1's room was located near the nurses' station with a telephone. The oxygen storage room is located between R1's room and the nurses' station. On [DATE] at 1:50pm, V3 NP (nurse practitioner) stated that V3 is familiar with R1. V3 stated that R1 was alert and oriented x 0. […]