Citadel of Northbrook, The

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

60.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 308 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 26.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 212 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 158 beds and averages 133.7 residents a day — about 85% occupied, or roughly 24 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.24 hrs/resident/day on weekends vs 3.67 on weekdays — 12% thinner on weekends. RN hours go from 0.85 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 15 most serious are shown; the remaining 11 are one tap away and print in full.

• Actual harm · Gcited before2024-05-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. 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. R1 required substantial assistance with toileting, transfers, and bathing. Per CMS (Centers for Medicare and Medicaid Services) a BIMS score 0-7 notes severe cognitive impairment. R1's care plan, initiated 3/8/24, notes R1 is at risk for falls related to gangrene left toes, unsteadiness on feet, abnormalities of gait and mobility, lack of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 Autonomic Nervous System, Irritable Bowel Syndrome, Pulmonary Blastomycosis, Urinary Tract Infection, Neurological Dysfunction of Bladder, Anxiety Disorder, Major Depressive Disorder, Agoraphobia with Panic Disorder, Other Cord…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-08-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. R1 plan of care denotes R1 has difficulty hearing and visual deficits. R1 incident report to the department dated 8/6/2023 denotes in part, location of incident shower room, resident complained of pain on right leg upon assessment, noted right hip swelling and shortening of right leg no bruising or redness noted. NP (Nurse Practitioner) notify and assess resident in order to send resident to hospital for evaluation, resident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-01-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. These failures resulted in R6 sustaining 4 new facility acquired pressure ulcers on her right lower extremities. R25 sustaining 2 facility acquired pressure ulcers on the sacral pressure ulcer that further deteriorate with size, characteristic and appearance, and left heel pressure ulcer that was identified on its late…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-01-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide oral nutritional supplement as prescribed by physician. This failure resulted in a significant weight loss (>5% change over a span of 1 month and >10% change over a span of 6-month period) for 1 (R57) of 7 residents reviewed for nutrition in a total sample of 30. Findings include: On 01/17/23 at 12:16 PM, surveyor observed V10 (Certified Nursing Assistant/CNA) feeding R57 in the unit dining room, with R57 eating very slowly with eyes closed and overall poor intake less than 50% of lunch meal. No supplement observed on lunch tray. On 01/18/23 at 08:55 AM, surveyor observed V37 (Restorative Coordinator) feeding R57 in unit dining room. No commercial oral supplement observed on breakfast tray. No commercial oral supplement listed on R57's meal ticket. On 01/18/23 at 9:13 AM, V16 (Speech Language Pathologist) stated that R57 requires 1:1 feeding assistance. On 01/18/23 at 11:25 AM, V19 (Certified Nursing Assistant/CNA) re-weighed R57…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-21 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to provide dignity to resident while feeding. This deficiency affects one (R105) of three residents in the sample of 26 reviewed for Dignity Findings include: On 02/18/25 at 11:54 AM, R105 observed in dining room. On 02/18/25 at 11:56 AM, V16 (Certified Nurse Aide) observed feeding R105 while standing over resident. V16 said that he is aware that he needs to be sitting down to feed R105, said he had no chair available. On 2/18/25 at 11:59 AM, V15 (Unit Manager) said that all staff feeding residents should be sitting next to resident and not stand over the residents, chairs are available in dinning room. On 02/19/25 at 1:36 PM, V2 (Director of Nursing) said that staff should provide feeding assistance to resident while sitting next to resident to be at eye level and provide dignity to resident. Hand hygiene to performed before and after. Facility's policy on Assistance with Meals revised July 2017 Policy: Resident shall receive assistance with meals in a manner that meets the individual needs of each resident.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-21 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement its policy on resident self-administration by failure to perform an assessment conducted by IDT (Interdisciplinary Team) to determine safe self-medication administration of resident. The facility failed to obtained physician order for resident self-medication administration. The facility failed to ensure storage of medication in locked box in the resident room. The facility also failed to document, and care planned of resident self-administration of medication. This deficiency affects one (R36) of three residents in the sample of 26 reviewed for Resident Self-medication administration. Findings include: On 2/18/25 at 11:46AM, Observed R36 on semi-sitting position in bed with V13 RN (Registered Nurse). R36 is alert and oriented x 3 and can verbalize needs to staff. Observed eye drop medication unlabeled at bedside tray table. She said that it is her eye medication- Refresh eye drops, that she uses every 5 minutes due to severe eye…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure not to use multilayers of linen over the low air loss mattress as manufacturer recommendation to resident with Stage 4 pressure ulcers. This deficiency affects one (R30) of three residents in the sample of 26 reviewed for Wound care management. Findings include: On 2/19/25 at 9:57AM, Observed R30 lying on bed with Low air loss mattress. V19 said R30 has pressure ulcers, and the Wound care nurse does her wound dressings. V19 RN checked the linens over the LAL (Low air loss) mattress. Observed flat sheet and a folded linen in quarters over the mattress. R30 is wearing disposable brief. V19 said that R30 should only be on flat sheet over the LAL mattress. On 2/19/25 at 11:07AM, Informed V3 DON (Director of Nursing) of above observation. She said that resident on LAL mattress should only have flat sheet over the mattress. On 2/20/25 at 10:59AM, Observed R30 has flat sheet and folded linen over the LAL mattress. R30 wears disposable…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-21 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure that an ongoing assessment is rendered to identify change in limitation of a resident's left-hand range of motion. This deficiency affects one (R52) of three in a sample of 26 reviewed for Restorative nursing program. Findings include: On 2/18/2025 at 12:30 PM, observed with V5 (Restorative CNA) that R52 has a left-hand flexion contraction with no hand splint applied. V5 said that R52 should have a hand splint applied. On 2/20/2025 at 10:53 AM, V5 said that R52 is in bed mobility program, but she first observed R52's left-hand flexion contraction with the surveyor. V5 said that she notified V14 (LPN) and V9 (Restorative Nurse). On 2/18/2025 at 12:40 PM, showed observation made to V14 (LPN) that R52 has a left-hand flexion contraction. V14 said that R52 should have a splint applied to her left hand. On 2/20/2025 at 10:00 AM, V9 (Restorative Nurse), said that when V9 assessed R52 on 1/17/2025, V9 did not observed any limitation on range of motion (ROM) on R52 left hand. V9 said that decrease in R52's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-21 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to use appropriate infection control practices during feeding assistance and perform hand hygiene. This deficiency affects two (R30, R67) of three residents in the sample of 26 reviewed for Infection control protocol. Findings include: On 02/18/25 at 12:00 PM, R67 observed in dining area. On 2/18/25 at 12:00 PM, V17 (Registered Nurse) observed feeding R67 and then observed feeding another resident at the same table and no hand hygiene performed in between. V17 said that she knows she has to feed one patient at a time and said that she did not perform hand hygiene after feeding one resident and going to another. On 02/18/25 at 12:09 PM, V15 (Unit Manager) said all staff should perform hand hygiene before and after assisting with feeding resident. Hand sanitizer is available in unit and sink available to wash hands in dinning area for hand hygiene. On 02/19/25 at 1:36 PM, V2 (Director of Nursing) said expectation of staff when feeding resident is to perform hand hygiene before and after feeding resident and when…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-04-11 · tag F0658 — failed to meet professional standards of care — pattern
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to follow physician's orders and failed to administer medication in accordance with acceptable clinical practice for 9 (R1, R5, R7, R31, R43, R54, R78, R95, R99) of 9 residents reviewed for medication administration. Findings include: On 4/9/24 at 9:54AM V11 LPN (Licensed Practical Nurse) was observed completing 9:00AM medication administration. After holding one tablet metoprolol 25mg (milligrams) from R45, V11 returned to the medication cart, and placed the tablet back in the medication blister pack with unclean hands. V11 said, it was okay to return the medication because it did not fall on the floor. Surveyor observed V11 touch the medication with V11's bare hands and brought into the resident's room. The medication fell out of the medication cup and onto the tray. At the conclusion of the observation V11 said, although they had passed medications to all their residents, they did not sign out all the medications as given on the MAR (Medication Administration Record). Surveyor observed on the Electronic Health…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-11 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on Observation, Interview and Record Review, the facility failed to have a five percent (5%) or less medication error rate for one (R45) of one resident. There were 13 medication errors out of 34 medication opportunities, resulting in a 38.24% medication error rate. Findings include: On 04/09/24 at 09:14 AM V11 LPN (Licensed Practical Nurse) was observed administering 9:00AM medications to R45. When administering to R45, V11 said R45 takes medications whole, individually and in applesauce. R45 said R45 only wanted one pill prior to V11 administering, which V11 acknowledged. V11 administered medications by spoon and two pills were observed in the applesauce. R45 spit one small yellow pill out and nurse gathered with tissue, not questioning or re-offering. After observing administration, V11 was about to throw out the tissue when surveyor asked to identify the tablet. V11 said V11 didn't know what the tablet was, but then recognized it as digoxin against the medication card. V11 said this is a heart medication. Administered medications for R45 were reconciled against the current…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-04-11 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to follow hand hygiene procedures during medication administration for two (R23 and R45) residents reviewed for infection control. Findings include: On 4/9/24 at 9:14AM, V11 LPN (Licensed Practical Nurse) was observed preparing and administering medications. During this observation, V11 did not perform hand hygiene at the beginning of the observation. Surveyor observed V11 remove tablets from medication blister cards popping the medications in V11's hand and placed them in a medication cups. As V11 moved across the cart, touching cards and common surfaces, V11 did not stop to perform hand hygiene. V11 continued this practice for two different residents R23 and R45. Facility Policy titled Medication Administration (Pharmacy) revised 10/2014 states in part: Preparation: 2. Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2023-01-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to store and prepare food under sanitary conditions. This has the potential to affect all 141 residents that receive nutrition services from the kitchen. Findings include: On 01/17/2023 at 09:16 AM, surveyor conducted an initial tour of the kitchen with V26 (Dietary Manager). At 09:24 AM, surveyor inspected facility's walk-in refrigerator that also leads into the freezer. Surveyor observed a cart full of individual whoopie pies and puddings uncovered in the middle of the refrigerator. V26 stated kitchen staff prepared them in the morning and facility will serve them for lunch. In the freezer, surveyor observed ice build-up at the bottom of the freezer's left fan. There was a box of breakfast sausage underneath the fan. The box had a build-up of ice on the top left side. V26 stated the freezer is supposed to go through a weekly defrost cycle. On 01/18/2023 at 09:00 AM, surveyor conducted a follow-up kitchen tour. Surveyor observed the facility's knife holder that was fastened on the wall. Knife holder had dust and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-01-20 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure that residents' call light cords were within reach for 4 (R15, R82, R128, R239) out of a total sample of 30 residents. Findings include: On 01/17/2023 at 12:22 PM, surveyor entered R128's room for interview. R128 asked surveyor for more soup. Informed R128 of surveyor's roles. R128 stated [R128] doesn't know how to call staff. R128 began feeling around the bed. Surveyor noted R128's call light cord was on the floor near the head of the bed frame. R128 stated I can't reach it all the way back there. I want to call for more soup. I have nothing to call if I want something. R128 stated [R128] was feeling frustrated. At 12:33 PM, surveyor attempted to flag/call someone down the hallway. Could not reach staff. Surveyor went to nurses' station. V25 (Certified Nurse Aide/CNA) stated V25 was assigned to R128. V25 entered R128's room. V25 stated R128's call light cord was on the floor out of reach for R128. On 01/18/2023 at 03:10 PM, surveyor reviewed R128's comprehensive care plan. Focus created 1/17/2023…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$25,126 in federal fines across 2 penalties.

• $10,033 — penalty dated 2024-01-27
• $15,093 — penalty dated 2023-08-21

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to CITADEL HEALTHCARE — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $1.4M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL