F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on observation, interview, and record review the facility failed to ensure the indwelling urinary bag
was placed in a dignity bag for 1 of 2 residents (R112) reviewed for indwelling urinary catheter in a sample
of 15.
Findings include:
On 4/11/2023 at 10:45am R112 was observed in bed with his urinary collection bag facing the door without
a privacy bag covering.
On 4/11/2023 at 10:46am V10(Certified Nursing Assistant/CNA) said the urinary collection bag should have
a privacy bag always covering it.
On 4/13/2023 at 12:46pm V3(Assistant Director of Nursing/ADON) said I expect all urinary collection bags
to have a privacy bag always covering it.
An Order Summary Report dated 4/1/2023-4/30/2023 indicates R112 has a diagnosis of Benign Prostatic
Hyperplasia without lower urinary tract symptoms. A care plan that indicates R112 has a focus of
Neurogenic bladder with interventions that the Catheter must have a dignity bag covering it.
Facility Policy: Reviewed December 2018 Quality of Life-Dignity
Policy Statement
Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect,
and individuality.
Policy interpretation and Implementation
11. Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote
dignity and assist residents as needed by:
a. Helping the resident to keep the urinary catheter bags covered.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
145932
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145932
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Citadel Care Center-Wilmette
432 Poplar Drive
Wilmette, IL 60091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to implement their fall intervention for one
resident (R22) out of nine residents reviewed for fall in the sample of 15.
Finding includes:
R22 was admitted on [DATE] with diagnosis not limited to unspecified dementia, psychotic disturbance, and
anxiety disorder.
Nursing: Quarterly Morse Fall Scale dated 3/16/23 documents: R22 Score = 60 and category: High Risk for
Falling.
R22 had a fall on 12/12/2022. R22 Care plan fall intervention on 12/12/2022 documents: floor mattress next
to bed when R22 is in bed.
On 4/11/22 at 10:30 am, R22 was observed sleeping in bed and no floor mattress was next to her bed.
On 4/11/2023 at 4:00 pm, R22 was observed again sleeping in bed and no floor mattress was next to her
bed.
On 4/12/2023 at 12:07, R22 was observed for sacral wound dressing change by V9 (Wound Care Nurse)
and no floor mattress was next to her bed.
On 4/12/2023 at 3:38 pm, R22 was observed in her bed with V4 (Care Plan Coordinator/MDS) and no floor
mattress was next to her bed. V4 said that R22 should have a floor mattress next to her bed.
Facility: Falls and Fall Risk, Managing Policy Statement:
Based on previous evaluations and current data, the staff will identify interventions related to the resident's
specific risks and causes to try to prevent the resident from falling and to try to minimize complications from
falling.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145932
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145932
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Citadel Care Center-Wilmette
432 Poplar Drive
Wilmette, IL 60091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on observation, interview, and record review the facility failed to ensure that the urinary drainage bag
was placed below the bladder for 1 of 2 residents (R112) reviewed for urinary catheter in a sample of 15.
Residents Affected - Few
Findings include:
On 4/11/2023 at 10:45am R112 was observed in bed with his urinary drainage bag positioned above his
waist.
On 4/11/2023 at 10:46am V10(Certified Nursing Assistant/CNA) said the urinary collection bag should
place below his waist.
On 4/14/2023 at 12:50pm V3(Assistant Director of Nursing/ADON) said I expect all urinary drainage bags
to be positioned below the waist to prevent a urinary tract infection.
An Order Summary Report dated 4/1/2023-4/30/2023 indicates a diagnosis of Benign Prostatic
Hyperplasia without lower urinary tract symptoms and Neuromuscular dysfunction of bladder, unspecified.
A care plan with a focus that indicated R112 has an indwelling catheter related to neurogenic bladder. An
intervention that indicates R112's indwelling catheter and tubing below the bladder level and away from the
entrance room door.
Reviewed September 2019 Catheter Care, Urinary
Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections.
Preparation: Maintaining Unobstructed Urine Flow
3. The urinary drainage bag must be always held or positioned lower than the bladder to prevent the urine
in the tubing and drainage bag from flowing back into the urinary bladder.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145932
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145932
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Citadel Care Center-Wilmette
432 Poplar Drive
Wilmette, IL 60091
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to monitor and maintain the resident's personal
refrigerator temperature for two of four residents (R12, R52) reviewed for food safety in a sample of 15.
Findings include:
R12's order summary report dated 4/13/2023 indicated admission date of 4/8/2023 and diagnosis of but not
limited to pure hypercholesterolemia.
R52's order summary report dated 4/13/2023 indicated admission date 3/22/2023 and diagnosis of but not
limited to depression.
On 04/11/2023 at 10:11 AM during observation with V3 (Assistant Director of Nursing), R12's personal
refrigerator temperature had no April 2023 log observed by the refrigerator. The refrigerator was observed
with multiple food items inside. V3 stated that resident's refrigerator temperature should be checked daily by
maintenance.
On 04/11/2023 at 10:41 AM during observation with V6 (Registered Nurse), R52's personal refrigerator
temperature log for April 2023 was noted blank and food items were observed inside the refrigerator. V6
said that resident's refrigerator temperature should be checked daily by the Certified Nursing Assistants
(CNAs).
On 04/13/2023 at 2:36PM, V15 (Maintenance Director) said that resident's refrigerator should be checked
by the managers assigned to rooms daily and if they are not available, the CNAs or unit staff are expected
to check it. He also mentioned that he checks it each week or throughout the week to see if it is being
monitored.
Facility Policy: Title: Food [NAME] in By Family or Visitors - Personal Refrigerators
Procedure: Personal refrigerator temperatures should be maintained at 41 degrees Fahrenheit or below.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145932
If continuation sheet
Page 4 of 4
