Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Citadel At Saint Benedict during CMS and state inspections, most recent first.
Multiple leftover food items were found in the kitchen refrigerator and cooler without proper labeling or dating, and some were past their labeled dates. Sanitizer buckets used for cleaning surfaces had chemical concentrations below the required 200-400 ppm range. The three-compartment sink was not used as required for washing, rinsing, and sanitizing kitchenware, with staff instead using a hose and the sink not being fully operational due to faulty plugs.
A cognitively impaired female resident with a history of falls was left unsupervised near the nurse's station, resulting in her standing up from her wheelchair, falling, and sustaining a forehead abrasion. Staff did not provide the close monitoring required for her high fall risk status, and after the fall, she was not sent for hospital evaluation or x-rays, with only neuro checks performed. The care plan and fall risk assessment were found to be inadequate and not reflective of her needs.
Two residents with complex medical conditions did not receive their scheduled medications within the required time frame, as an LPN administered doses late without documenting the delay or notifying a physician. The errors occurred due to workload and resident preferences, resulting in a medication error rate of 13.79%, and were not in compliance with facility and pharmacy policies.
Two residents at an LTC facility suffered serious injuries due to inadequate fall prevention measures. One resident, left unsupervised in the dining room, fell and sustained thoracic spine fractures. Another resident rolled out of bed, resulting in a hip fracture, as the bed was not in the lowest position and lacked a floor mat. The facility's policies on accident prevention and fall management were not properly implemented, and documentation of fall risks was inaccurate.
A facility failed to administer pain medication as ordered for a resident with a pubis ramus fracture. Despite recorded pain levels and physician orders for acetaminophen and Norco, the RN did not administer any pain medication, citing a lack of reported pain and unawareness of the fracture. The medication administration record showed no documentation of pain medication being given during episodes of pain.
A resident in an LTC facility experienced verbal and mental abuse from an RN after a fall. The RN questioned the resident in a loud, accusatory manner while she was on the floor, making inappropriate remarks. A CNA witnessed the incident and objected to the RN's behavior, leading to a verbal altercation. The facility's abuse prevention policy was not followed, as the RN's actions were deemed abusive by staff and administration.
A resident in an LTC facility, who was cognitively intact and had multiple medical conditions, reported being physically abused by a CNA. The CNA allegedly grabbed the resident's arm, pulled out her oxygen tubing, and forced her into a shower, resulting in bruising. The facility's investigation, supported by staff and resident interviews, confirmed the abuse, leading to the CNA's termination.
A resident with multiple health conditions was injured during a transfer when a CNA used a mechanical lift without assistance, contrary to facility procedures requiring two staff members. The resident sustained bruises due to rough handling, and the incident was not documented in the medical record. Interviews confirmed the CNA's failure to follow safety protocols.
A resident was hospitalized with severe sepsis and acute kidney injury due to the facility's failure to monitor and assess urinary catheter obstruction and urine output. Staff did not consistently document catheter care or urine output, and there were no records of catheter changes for nearly three months. The resident's condition deteriorated, leading to an emergent hospitalization where the catheter was found to be obstructed and calcified.
The facility failed to maintain a medication error rate below 5%, with agency RNs leaving medications at the bedside, administering medications late, and not following physician orders. The DON confirmed that the facility's policy requires adherence to the five rights of medication administration and staying with residents to ensure they take their medications.
The facility failed to ensure proper medication administration, resulting in significant errors for three residents. Medications were left at the bedside, administered late, and not properly documented, with staff admitting to not following protocol.
Deficient Food Storage, Sanitation, and Three-Compartment Sink Use
Penalty
Summary
The facility failed to adhere to established policies and professional standards regarding food storage, sanitation, and cleaning procedures in the kitchen. During an observation, multiple leftover food items, including drained pineapple, apple sauce, dried peas, peaches, cream of mushroom, and a sandwich with lettuce and tomato, were found in the walk-in refrigerator and reach-in cooler without proper labeling or dating. Some items were past their labeled dates, while others were undated, contrary to facility policy requiring all foods to be labeled and dated, and leftovers to be used or discarded within 72 hours. Sanitizer buckets used for cleaning kitchen surfaces were found to have chemical concentrations below the required range. Testing of the red sanitizer buckets revealed concentrations of 0-100 ppm and 100 ppm, while the facility's policy and manufacturer instructions require a range of 200-400 ppm for effective sanitation. The dietary staff confirmed the use of ammonium chloride as the sanitizer and acknowledged the need for correct concentration, but the solution in use did not meet these standards. Additionally, the three-compartment sink, which is required for proper manual washing, rinsing, and sanitizing of kitchenware, was not being used according to policy. Soiled pots, pans, and utensils were observed in all three compartments, and the sink was not filled with water as required. Instead, staff were using a hose connected to detergent to rinse and wash items, and the sanitizer compartment was not in use due to faulty sink plugs. The dietary manager confirmed that the sink had not been fully operational for several weeks, and there was no documented work order to repair the issue.
Failure to Provide Adequate Supervision and Assessment for High Fall Risk Resident
Penalty
Summary
A cognitively impaired female resident with a history of falls and multiple medical diagnoses, including dementia, unsteadiness on her feet, and abnormal posture, was not provided with appropriate and sufficient supervision despite being identified as a high fall risk. The resident's care plan did not address the need for constant close supervision, and her fall risk assessment was inaccurate, failing to reflect a recent fall. On the day of the incident, the resident was left unsupervised near the nurse's station while her assigned CNA was attending to another resident in a different hall, and no staff were present at the nurse's station at the time of her fall. The resident attempted to stand from her wheelchair, lost her balance, and fell face down, resulting in a bloody abrasion on her forehead. Staff responded after hearing the fall, but the resident was not under direct supervision at the time, despite staff acknowledging that she required constant monitoring. Interviews revealed inconsistencies in staff accounts regarding supervision and the implementation of fall precautions, with some staff stating that residents at high risk of falls should be closely supervised by sitting alongside them or being near them at all times. Following the fall, the resident was assessed by staff, who noted abrasions and bleeding but did not send her to the hospital for further evaluation. The facility did not conduct x-rays or a comprehensive injury assessment, relying instead on neuro checks and monitoring. The incident was not reported to the State, as the facility determined there was no major injury without hospital evaluation. The lack of accurate assessment, supervision, and appropriate response to the fall constituted a failure to ensure the resident's safety and prevent accidents.
Medication Administration Errors Due to Delayed Dosing and Lack of Documentation
Penalty
Summary
Surveyors identified that the facility failed to administer medications according to physician orders for two out of five residents observed during a medication pass, resulting in a medication error rate of 13.79% (4 errors out of 29 opportunities). Specifically, an LPN administered medications to two residents outside the scheduled administration times without documenting the delay or notifying the physician, as required by facility and pharmacy policy. The medications involved included Ferrous Sulfate and Furosemide for one resident, and Carvedilol and Furosemide for another, all of which were scheduled to be given twice daily at specific times. The residents involved had complex medical histories, including diagnoses such as heart failure, anemia, hypertension, dementia, and other chronic conditions. The LPN stated that delays occurred due to the time required to administer medications to other residents, resident preference for later administration, and a heavy workload of 30 residents. There was no documentation in the electronic medical records to account for the delayed administration or any physician notification, which is contrary to both facility and pharmacy policies that require timely administration and proper documentation of any deviations.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to develop and implement individualized care plan interventions to reduce the risk of injury from falls, affecting two residents. One resident, with a history of hemiplegia, cognitive impairments, and a history of falls, was left unsupervised in the dining room. The resident attempted to walk after a family visit, fell, and sustained three compression fractures of the thoracic spine. The Certified Nursing Aide (CNA) responsible for monitoring the dining room left to assist another resident without ensuring coverage, resulting in the resident being unsupervised at the time of the fall. Another resident, with a history of dementia and repeated falls, was observed rolling out of bed by a Registered Nurse (RN). The resident's bed was not in the lowest position, and there was no floor mat in place, which contributed to the resident sustaining a left comminuted hip fracture. The Director of Nursing (DON) acknowledged that the intervention of placing the bed in the lowest position was not documented in the resident's care plan and was not effective in preventing further injury. The facility's policies on accident prevention and fall management were not adequately followed, as evidenced by the lack of proper supervision and ineffective interventions for residents at risk of falls. The facility's documentation and assessment of fall risks were also found to be inaccurate, indicating a need for improved staff training and adherence to care plans.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as ordered by the physician for a resident reviewed for pain management. The resident had physician orders for acetaminophen and Norco to be administered as needed for pain. On the day of the incident, the resident experienced a fall from bed and had a documented history of a pubis ramus fracture. Despite recorded pain levels of 5, 4, and 1 throughout the day, the Registered Nurse did not administer any pain medication, as the nurse did not recall being informed of the resident's fracture and assessed the resident as not having pain. The medication administration record did not document any administration of pain medication during these episodes of pain.
Resident Subjected to Verbal and Mental Abuse by Staff
Penalty
Summary
The facility failed to ensure a resident was free from abuse, as evidenced by an incident involving a resident, R3, who experienced verbal and mental abuse from a staff member. R3, who had a history of falls and was cognitively intact, fell while attempting to go to the bathroom independently. After the fall, R3 was found on the floor by a CNA, V17, who then called for assistance from an RN, V18. Upon entering the room, V18 began questioning R3 in a loud and accusatory manner, which R3 found embarrassing and upsetting. During the incident, V18 stood over R3, who was still on the floor, and questioned her in a manner that was perceived as scolding. V18's questioning included inappropriate remarks such as, "How does it feel to be down there? Are you proud of yourself?" This behavior was witnessed by V17, who expressed discomfort with V18's conduct and attempted to intervene. Despite V17's objections, V18 continued to question R3 aggressively, leading to a verbal altercation between V17 and V18 in front of R3. The facility's policy on abuse prevention was not adhered to, as the actions of V18 were considered verbal and mental abuse by both the CNA and the Director of Nursing. The incident was reported to the facility administrator, who acknowledged the inappropriate nature of V18's behavior. The facility's abuse prevention program emphasizes the importance of maintaining a resident-sensitive environment, which was not upheld in this situation.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal, physical, and mental abuse by an employee, specifically a CNA. The incident involved a resident who was cognitively intact and had multiple medical diagnoses, including anemia, hypothyroidism, type 2 diabetes, and hypertension. The resident reported that the CNA grabbed her arm aggressively, pulled out her oxygen tubing, and forced her into a shower, resulting in new bruising on her upper right forearm and under her right breast. The resident expressed fear and unhappiness, not wanting to be left alone at the facility. The incident was reported by the nursing staff to the facility's administration, and a body check confirmed the presence of new bruising. The CNA involved was suspended pending investigation, and the police were called to investigate the allegations of physical harm. Interviews with the resident, her daughter, and various staff members corroborated the resident's account of the CNA's rough handling and improper use of a mechanical lift. The CNA denied the allegations but admitted to using the lift without assistance, contrary to facility policy. The facility's investigation revealed that the CNA had been recently hired and had worked only a few shifts before the incident occurred. Despite the CNA's denial of the allegations, the evidence, including the resident's consistent statements and the physical signs of bruising, led to the CNA's termination. The facility's abuse prevention policy emphasizes the residents' right to be free from abuse, and the CNA's actions were found to be in violation of this policy.
Improper Use of Mechanical Lift Leads to Resident Injury
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in injury. The resident, who had multiple diagnoses including anemia, hypothyroidism, type 2 diabetes, and muscle weakness, required assistance from two staff members for transfers using a mechanical lift as per their care plan. However, a CNA attempted to transfer the resident alone using a sit-to-stand lift, which was against the facility's procedure that mandates two staff members for such transfers. This improper handling led to the resident sustaining bruises on the upper right forearm and under the right breast. The incident occurred when the CNA, identified as V12, used the sit-to-stand lift without assistance, despite another CNA, V13, offering help. V12 was reported to have been rough during the transfer, causing the resident to slide back and forth in the chair. The resident, who was cognitively intact, reported the rough handling and the resulting bruises. The facility's Director of Nursing confirmed that the sit-to-stand lift should always be operated by two people, emphasizing that this was a standard safety protocol. Interviews with staff revealed that V12 did not follow the proper procedure and failed to document the transfer in the resident's medical record. The CNA admitted to using the lift without assistance and acknowledged the lack of clear instructions on how to transfer residents. The facility's procedure for using mechanical lifts clearly states the need for two nursing associates to perform the task, highlighting a breach in protocol that led to the resident's injury.
Failure to Monitor Urinary Catheter Leads to Severe Sepsis
Penalty
Summary
The facility failed to monitor and assess for signs of urinary catheter obstruction and monitor urine output for a resident, resulting in the resident's emergent hospitalization and diagnosis of severe sepsis and acute kidney injury. The resident, a [AGE] year-old female with multiple diagnoses including Alzheimer's Disease and Peripheral Vascular Disease, had a physician order for urinary catheter care every shift and as needed. However, the facility's staff did not consistently document catheter care or urine output, and there were no records of catheter changes between 02/01/2024 and 04/22/2024. Additionally, vital signs were not documented in the days leading up to the resident's hospitalization, with the last known set checked on 02/16/2024. Interviews with staff revealed that both nurses and CNAs were responsible for urinary catheter care, but there was a lack of consistent documentation and communication regarding the resident's condition. The LPN and CNAs involved did not notice or document any changes in the resident's urine output or appearance, and there was no daily urinary catheter assessment documentation required by the facility. The Quality Director/Infection Preventionist confirmed that urinary catheter care was documented inaccurately, with records showing care documented even after the resident was transferred to the hospital. The hospital record indicated that the resident was found unresponsive with tachycardia and hypotension, and the urinary catheter had calcified to the point of obstruction, leading to obstructive uropathy and a subsequent urinary tract infection. The facility's policy on urinary catheter care emphasized the importance of monitoring urine levels and reporting any changes, but this was not consistently followed. The lack of proper monitoring and documentation ultimately led to the resident's severe sepsis and acute kidney injury.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, as evidenced by a medication pass observation revealing 26 medication administration errors out of 31 opportunities, resulting in an 83.87% error rate. During the observation, an agency RN left nine morning medications at a resident's bedside, which were later administered along with the noon medications without verifying the resident's blood pressure as required by the physician's orders. The resident confirmed that the nurse left the medications earlier in the morning, and the nurse admitted to not staying with the resident to ensure the medications were taken. Another agency RN, who arrived late to cover for an absent nurse, administered medications to a resident but failed to administer all the prescribed 9:00 AM medications, despite documenting them as given. Additionally, this nurse administered medications to another resident, including insulin and other prescribed drugs, but did not follow the scheduled times and documented medications as administered that were not observed during the survey. The Director of Nursing confirmed that the facility's expectations are to follow the five rights of medication administration and to stay with residents to ensure they take their medications. The facility's policy also states that medications should be administered in a safe and timely manner, and residents may only self-administer medications if determined by a physician. However, none of the residents involved had active physician orders to self-administer medications, and no relevant documentation was provided by the facility for review.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that medical staff were properly trained to administer prescribed medications according to physician's orders, resulting in significant medication errors for three residents. One resident was observed with a plastic medicine cup containing six pills left at her bedside, which she self-administered without supervision. The reconciliation of her medication administration record (MAR) showed discrepancies, including the absence of blood pressure monitoring before administering antihypertensive medication, as required by her physician's orders. The nurse responsible admitted to leaving the medications at the bedside due to the resident's preference for privacy, despite knowing it was against protocol. Another resident had her 9:00 AM medications left at her bedside and was later administered these medications along with her noon medications by the same nurse. The nurse acknowledged that she should have stayed with the resident to ensure the medications were taken and admitted to administering the 9:00 AM medications late. The MAR confirmed that the medications were documented as administered, but the nurse did not follow the proper procedure of observing the resident taking the medications. A third resident did not receive all of her prescribed 9:00 AM medications, although the MAR indicated they were administered. The nurse covering for another staff member admitted to administering the medications late and not following the proper protocol. The Director of Nursing and the Nurse Practitioner both emphasized the importance of following the five rights of medication administration and ensuring that medications are administered within the appropriate time window, with necessary observations such as blood pressure checks for antihypertensive medications.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Niles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elevate Care North Branch | 0.2 mi | ★★★★★ | 3 | 0 |
| Celebrate Senior Living Niles | 0.4 mi | ★★★★★ | 1 | 0 |
| Aperion Care Niles | 0.5 mi | ★★★★★ | 0 | 0 |
| Elevate Care Regency | 0.6 mi | ★★★★★ | 2 | 2 |
| Norwood Crossing | 1.5 mi | ★★★★★ | 5 | 0 |
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