Cycle 1
Health 2025-02-20 · Fire 2025-02-20
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Wilmette, IL
Citadel Care Center-Wilmette
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
432 Poplar Drive, Wilmette, IL
(847) 216-5000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Citadel Healthcare
Operator or chain grouping
Approved since
1997-04-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 3 overall / 4 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.73
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.45
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.05
CMS adjusted total nurse staffing hours
Case-mix index
1.77
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,501
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9842
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.45% · Performance 21.98% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.16
Baseline 6.09% · Performance 6.59% · Measure score 4.16 · Achievement 4.16 · Improvement 0
Total nurse turnover
6.46
Baseline 34.54% · Performance 37.29% · Measure score 6.46 · Achievement 6.46 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.56 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.9% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 258 · Observed rate 6.59% · Lower 95% interval 6.62% |
| Discharge to community | 64.27% |
50.57%
13.7 pts better
|
Better than the National Rate · Eligible stays 251 · Observed rate 58.17% · Lower 95% interval 58.12% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98% |
95.27%
2.7 pts better
|
Numerator 147 · Denominator 150 |
| Falls with major injury | 0.67% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 150 |
| Discharge self-care score | 60% |
53.69%
6.3 pts better
|
Numerator 60 · Denominator 100 |
| Discharge mobility score | 69% |
50.94%
18.1 pts better
|
Numerator 69 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 150 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.59% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 159 · Observed rate 5.66% · Lower 95% interval 4.07% |
| Staff COVID-19 vaccination coverage | 94.39% |
8.2%
86.2 pts better
|
Numerator 101 · Denominator 107 |
| Staff flu vaccination coverage | 93.27% |
42%
51.3 pts better
|
Numerator 97 · Denominator 104 |
| Discharge function score | 63% |
56.45%
6.5 pts better
|
Numerator 63 · Denominator 100 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 74 · Denominator 74 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 56 · Denominator 56 |
| Resident COVID-19 vaccinations up to date | 23.53% |
25.2%
1.7 pts worse
|
Numerator 16 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
89.6%
5.3 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 80.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.7% |
91.6%
1.1 pts better
|
95.5%
2.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 95.8% |
50.3%
45.5 pts worse
|
11.4%
84.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 100.0% · Q3 94.3% · Q4 91.2% · 4Q avg 95.8% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
6.5%
6.5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
18.5%
7.8 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 17.1% · Q3 7.9% · Q4 7.9% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.2% |
22.8%
8.4 pts worse
|
16.7%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 33.3% · Q3 32.0% · Q4 34.6% · 4Q avg 31.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.7% |
17.2%
9.5 pts better
|
16.3%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 4.5% · Q3 4.2% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
15.0%
9.6 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 0.0% · Q3 2.6% · Q4 2.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.0% |
21.3%
4.3 pts better
|
19.8%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 12.3% · Q3 31.3% · Q4 11.2% · 4Q avg 17.0% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
5.2%
3.3 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.9% |
68.8%
17.1 pts better
|
81.7%
4.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 69.3% · Q2 78.4% · Q3 96.6% · Q4 98.6% · 4Q avg 85.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
14.0%
1 pts better
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 11.8% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.3%
1.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.0% |
63.0%
14 pts better
|
79.7%
2.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
26.2%
0.1 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.3% · Observed 25.0% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-25 · Fire 2024-04-25
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-04-14 · Fire 2023-04-14
7 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-02-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-02-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-20
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-02-20
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-04
F · Potential for more than minimal harm
2024-04-25
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-17
F · Potential for more than minimal harm
2023-04-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-04-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-04-14
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-04-14
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-04-14
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-04-26
E · Potential for more than minimal harm
2023-04-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-20
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-04
D · Potential for more than minimal harm
2023-12-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-12-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-12-18
D · Potential for more than minimal harm
2023-04-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-04-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-04-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-04-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-25
G · Actual harm
2023-04-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-25
Penalties and ownership
What sits behind the stars
Ownership
Aaron, Jonathan
5% Or Greater Direct Ownership Interest · Individual
Stern Family Investment Tr
5% Or Greater Direct Ownership Interest · Organization
Berger Fam Tr Ua 06252014
5% Or Greater Direct Ownership Interest · Organization
Israel Family Investment Trust
5% Or Greater Direct Ownership Interest · Organization
Israel Investment Tr
5% Or Greater Direct Ownership Interest · Organization
Aaron, Jonathan
Operational/Managerial Control · Individual
Graf, Marcella
Operational/Managerial Control · Individual
Olugbermiga, Adetola
Operational/Managerial Control · Individual
Robin, Jason
Operational/Managerial Control · Individual
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