Inspection visit
Inspection
20 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 20 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Residents Affected - Some
Based on observation, interview and record review, the facility failed to ensure resident's buttocks were not
exposed, provide dignified care while feeding the residents and failed to remove resident's urinal during
mealtime.
This applies to 4 of 4 residents (R85, R5, R91 and R113) reviewed for dignity in a sample of 32.
Findings include:
1. On 1/3/24 at 12:45 PM, R85 was sitting along with many other residents in the dining room for lunch with
his buttocks fully exposed.
On 1/3/24 at 12:50 PM, V5 (CNA-Certified Nursing Assistant) stated that leaving R85 exposed like that
violates his dignity.
On 1/3/24 at 3:00 PM, V4 (RN-Registered Nurse) stated, residents must be well groomed and the clothing
they wear should cover their body appropriately to maintain their dignity.
Facility policy on 'Quality of life - Dignity' dated 1/2024 showed, ' . A. Residents shall be treated with dignity
and respect at all times .'
2. On 1/2/24 at 1:02 PM, R91 was observed in her room in bed, with the head of the bed elevated about 45
degrees. R91's lunch tray was on her bedside table in front of her. V8 (Business Office Manager) came in to
R91's room and said that she was going to assist R91 with her lunch. V8 said that R91 was nonverbal and
had her health had recently declined. V8 informed R91 that she would be feeding her the lunch and instead
of sitting down level with R91 to assist her to eat, V8 stood up over R91 at her bedside and began feeding
her ice cream.
The facility's Assistance with Meals policy (revised 11/2019) states that feeding assistants will not stand
over residents while assisting with meals. R91's EMR (Electronic Medical Record) showed diagnoses of
dementia and gastro-esophageal reflux disease without esophagitis. R91's Minimum Data Set, dated
[DATE] showed that resident was unable to complete the cognition interview.
3. On 1/2/24 at 1:09 PM, R5 was observed in her room, in bed, sitting up. R5's lunch tray was on her
bedside table, in front of her. V6 (CNA/Certified Nurse Aide) came in the room, and asked if R5 needed
assistance with her meal, R5 said yes. V6 came and stood by R5's bedside and began to cut up
(continued on next page)
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 6
Event ID:
145956
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
145956
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/05/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Citadel at Casa Scalabrini
480 North Wolf Road
Northlake, IL 60164
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 0550
Level of Harm - Minimal harm
or potential for actual harm
the roasted pork loins in small pieces and began to feed her the pork loins, roasted potatoes and carrots.
V6 remained standing while feeding R5 her lunch.
R5's EMR showed diagnoses of spinal stenosis lumbar region, abnormal posture and lack of coordination.
R5's MDS dated [DATE] showed that R5's cognition is moderately impaired.
Residents Affected - Some
4. On 1/2/24 at 1:16 PM, R113 was sitting up by the side of the bed in the room eating his lunch. There was
a urinal that had 200 ml (milliliters) of urine on the bedside table next to his lunch tray. Surveyor asked R113
if there was a reason he had the urinal on his bedside table while eating, he shook his head no; surveyor
asked if he would like it emptied, he nodded his head yes.
R113's EMR showed the following diagnosis of chronic obstructive pulmonary disease, asthma, and benign
prostate hyperplasia. R113's MDS dated [DATE] showed that R113's cognition is moderately impaired.
On 1/4/24 at 10:15 AM, V3 (DON/Director of Nursing) said that staff should sit next to residents while
assisting with feeding, due to dignity and the urinal with urine should not be on the bedside table along with
the meal trays as it is a dignity issue as well.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145956
If continuation sheet
Page 2 of 6
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
145956
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/05/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Citadel at Casa Scalabrini
480 North Wolf Road
Northlake, IL 60164
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 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to have call lights accessible to
dependent residents.
Residents Affected - Few
This applies to 1 of 4 residents (R26) reviewed for accommodation of needs in a sample of 32.
The findings include:
On 01/02/2024 at 11:44 AM, R26 was in his room, lying on bed. The room's right window was open. The
room felt cold. R26's call light was on the floor on the right side of the bed. R26 said he was transferred
from his previous room to his current room at 10:30 AM on 01/02/2024. R26 said he has been looking for
his call light since his transfer because the room was too cold. He said he was upset because his old room
had everything he needed, and his new room did not even have a call light. He said he has been calling out
for help but nobody came to his room.
On 01/04/2024 at 11:44 AM, V3 (DON-Director of Nursing) said after a resident transfers room, she expects
staff to orient resident to set up of new room and make sure call light is within reach. She said call light
should always be within reach for safety purposes.
Facility's Policy on Answering the Call Light dated 10/2017 and revised on 12/2017 stated the following:
.General Guidelines .E. When the resident is in bed or confined to a chair be sure the call light is within
reach of the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145956
If continuation sheet
Page 3 of 6
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
145956
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/05/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Citadel at Casa Scalabrini
480 North Wolf Road
Northlake, IL 60164
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
.
Residents Affected - Few
Based on observation, interview and record review, the facility failed to ensure aspiration precautions were
followed in accordance with professional standards of practice and provider recommendations.
This applies to 1 of 1 resident (R75) reviewed for dysphagia in a sample of 32.
Findings include:
On 1/2/24 at 2:15 PM, R75 was eating lunch in bed with head of bed raised at 45 degrees angle. No staff
was near R75. R75 drank juice with straw. At the head-end of the bed, a notice showed 'swallow strategies'
that included for R75 to sit up at 90 degree angle for meals, use no straws, and alternate food solids and
liquids.
The next day on 1/3/24 at 10:00 AM, R75 was sitting in her bed at a 45 degree angle and had a nutritional
shake with a straw in front of her and she had finished the carton. R75 also had a straw in her water jug. No
staff were near R75.
On 1/4/24 at 11:30 AM, the Surveyor visited R75 with V3 (DON-Director of Nursing) and observed R75 was
in her bed, again at a 45 degree angle, and she had an empty nutritional shake carton in front of her with a
straw in it. V3 (DON) stated, the swallow precaution instructions are put up on the wall for staff to follow so
that R75 will not aspirate. V3 (DON) stated that R75 should not have had straw in her liquids, she should be
sitting upright at a 90 degree angle, and staff must watch to ensure R75 alternates solid and liquid food.
R75's January 2024 Physician Orders showed, [R75] must be in upright position for all meals due to
aspiration precaution.
The facility's 1/2024 Aspiration Precautions policy showed, encourage resident to sit upright when taking
anything by mouth Follow speech pathology recommendations from swallow assessments . R75's 10/13/21
Speech Therapist's swallow and discharge summary showed, [R75] will safely swallow thin liquids via
teaspoon . R75's 6/2/23 Speech Therapist Progress notes showed . Patient will demonstrate the ability to
safely and efficiently consume thin liquid trials via straw with clinician only without overt s/s aspiration or
any noted difficulty .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145956
If continuation sheet
Page 4 of 6
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
145956
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/05/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Citadel at Casa Scalabrini
480 North Wolf Road
Northlake, IL 60164
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 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
Based on observation, interview and record review, the facility failed to verify placement of gastrostomy
tube (G-tube) prior to administering medications through the G-tube and failed to flush the G-tube in
between medication administration.
This applies to 1 of 4 (R82) residents reviewed for medication administration via G-tube in a sample of 32.
The findings include:
On 1/3/24 at 1:12 PM, V7 (RN/Registered Nurse) went to R82's room to administer medications via G-tube.
V7 informed R82 of the medication administration. R82 was on continuous g-tube feeding; V7 paused R82's
feeding and the feeding tubing remained connected. A second lumen was present on R82's G-tube and it
was capped. Without uncapping R82's second lumen or disconnecting the feeding, V7 used her
stethoscope to listen to R82's lower abdomen. V7 proceeded to flush the G-tube with 10 ml (Milliliters) of
water, administered Diltiazem 120 mg (milligrams) without flushig with water, then administered liquid
Metoclopramide 5 ml, then flushed the G-tube with 10 ml of water after medication administration.
R82's EMR (Electronic Medical Record) showed the following diagnoses of hemiplegia following cerebral
infarction affecting right dominant side, dysphagia following unspecified cerebrovascular disease and
aphasia following cerebral infarction. R82's POS (Physician Order Sheet) had the following orders of
Diltiazem 120 mg tablet administer one tablet by g-tube route three times daily; Metoclopramide 5 mg/5 ml
solution administer every 8 hours by g-tube three times daily. Check for G-tube patency/placement at med
pass and as needed.
On 1/3/24 at 1:19 PM, V7 said she should have checked for the G-tube placement prior to administering
medications and she should have flushed the G-tube between each medication administration.
On 1/4/24 at 10:20 AM, V3 (DON/Director of Nursing) said the nurses are to check for G-tube placement by
checking residual prior to medication administration to prevent complications and aspiration, and the nurse
should flush the G-tube in between each medication.
The facility's Administering Medications Through an Enteral Tube policy (revised 1/2020) states to verify
placement of the feeding tube; if administering more than one medication, flush with 15 ml of warm water
(or prescribed amount) between medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145956
If continuation sheet
Page 5 of 6
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
145956
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/05/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Citadel at Casa Scalabrini
480 North Wolf Road
Northlake, IL 60164
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation, interview and record review, the facility failed to remove lint from the facility's clothes
dryers.
Residents Affected - Many
This has the potential to affect all residents residing in the facility, staff, and visitors.
Findings include:
The facility's 1/2/24 Centers for Medicare and Medicaid Services Form 671 form showed a resident census
of 156 residents.
On 1/4/24 at 9:46am, all the facility's five dryers were observed not in use and with lint in the lint
basket/catchers. The baskets all had lint on the sides and bottom of the baskets, and the lint in each basket
was about ½ inch thick.
On 1/04/24 at 9:46am, V9 (Laundry Staff) said that she did not remember if she had cleaned out the dryers
today or not. V9 said that she does not log it when she cleans out the lint baskets and she did not know
how often she should clean the lint out- maybe once a day or a few times a day. At 9:52 am, V10 (Laundry
Supervisor) verified there was lint in all five dryers and the staff are not logging when they clean out the lint
traps and they are supposed to. V10 said she did not know that the lint baskets are supposed to be cleaned
out after each load. V10 said she thought the last time the staff logged cleaning out a lint trap was in July
2023.
On 1/04/24 at 10:23 am, V11 (Director of Facilities Management.) said that the lint should be removed after
every load because it could be a fire hazard, even after one load. On 1/04/24 at 10:23 am V10 (Laundry
Supervisor) said that it is a fire hazard if the lint is not cleaned out of the dryer after each load. On 1/04/24
at 11:35 PM V1 (Assistant Administrator) said that her expectations are that the staff clean out the lint from
the dryers after each load and to log it on the sheet for safety issues and to eliminate a fire hazard. On
1/04/24 at 1:28pm V11 said that on average the facility does 20 loads a day, every day.
The facility's Daily Dryer lint logs showed only three pages, May (no year shown)- total 23 entries,
May/June (no year shown)- 22 entries, & July (no year shown)- 9 entries.
A review of the facility's Logbook Documentation [company name] Tels. forms dated 1/3/2024, 12/26/23,
12/18/23, 12/11/23 & 12/4/23 showed, under Steps:
Confirm that the lint is removed from the stack and inside the dryer. It is a fire hazard and a code violation if
this is not maintained. The forms showed under Lint Catch/Screen - Lint catchers should be cleaned
AFTER EACH LOAD. The facility's undated dryer manual, (ADG-758 [Gas DSI] Installation Manual)
showed, Routine Maintenance- A. CLEANING Warning: lint from most fabrics is highly combustible. The
accumulation of lint can create a potential fire hazard .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145956
If continuation sheet
Page 6 of 6
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Back to topCitations
20 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0133GeneralS&S Dpotential for harm
Install a two-hour-resistant firewall separation.
- 0211GeneralS&S Dpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0271GeneralS&S Epotential for harm
Have exits that are accessible at all times.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0341GeneralS&S Epotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0342GeneralS&S Epotential for harm
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0531GeneralS&S Fpotential for harm
Have elevators that firefighters can control in the event of a fire.
- 0541GeneralS&S Epotential for harm
Install properly constructed and protected linen or trash chutes.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
- 0781GeneralS&S Epotential for harm
Have restrictions on the use of portable space heaters.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the January 5, 2024 survey of CITADEL AT CASA SCALABRINI?
This was a inspection survey of CITADEL AT CASA SCALABRINI on January 5, 2024. The surveyor cited 20 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CITADEL AT CASA SCALABRINI on January 5, 2024?
Yes, 20 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.