Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Care Center-kankakee during CMS and state inspections, most recent first.
The facility failed to properly store and handle food, with expired items and improperly sealed food found in the kitchen. The freezer was not maintained at the required temperature, resulting in soft, unfrozen beef franks. The Dietary Manager confirmed these issues, which violated the facility's food storage policies.
The facility's QAA committee did not include the Medical Director, who had not attended any meetings in over a year. This was confirmed by interviews and a review of attendance sheets, which lacked the Medical Director's signature. The QAA committee must include the Director of Nursing Services, the Medical Director or their designee, at least three other staff members, and the infection preventionist, with one member in a leadership role. This deficiency potentially affects all 88 residents.
A resident with moderate cognitive impairment and Huntington's disease was observed with yogurt spilled on her clothing and face. Two staff members, a housekeeper and an LPN, passed by without assisting her, despite the facility's policy on dignity requiring staff to promote respect and assist residents. The DON acknowledged the incident as a dignity issue.
The facility failed to provide the SNFABN to residents discharged from Medicare Part A services with benefit days remaining. The BOM did not issue the SNFABN, believing it unnecessary if a NOMNC was provided. Upon review, both the BOM and Administrator acknowledged that SNFABNs should have been completed according to the facility's policy.
The facility failed to provide written notification to residents, their representatives, and the ombudsman regarding hospital transfers. This deficiency was identified for three residents, including one with multiple diagnoses who experienced a medical emergency. The administrator admitted to not issuing written documentation due to a lack of awareness of the requirement.
The facility failed to provide written notification of the bed-hold policy to three residents or their representatives upon transfer to a hospital. Despite the facility's policy requiring such notification, documentation was absent in the residents' medical records. The administrator confirmed the oversight.
The facility failed to provide adequate personal hygiene care for three residents dependent on staff for ADLs. One resident had long, jagged nails with a brown substance and oily hair, while another had oily hair and excessive facial hair, causing distress. A third resident had a brown substance under his nails and stated he provides his own nail care when given supplies. The facility's policy requires staff to assist residents unable to perform ADLs independently.
A resident with hemiplegia and hemiparesis following a cerebral infarction was observed without the prescribed right-hand palm protector on two occasions, despite a physician's order for it to be worn at all times except during care. The Restorative Nurse Manager confirmed the resident's need for the device, which was found in the resident's dresser instead of being worn, indicating non-compliance with the care plan.
A resident with severe cognitive impairment and multiple medical conditions, including a stage 4 sacral pressure ulcer and neuromuscular bladder dysfunction, had their indwelling catheter drainage bag improperly positioned during a wound care dressing change. The catheter bag was placed on the bed and left under the resident's leg, contrary to the care plan and facility policy, which require the bag to be positioned below the bladder to prevent urine backflow.
Improper Food Storage and Handling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food storage and handling protocols, as evidenced by the presence of expired food items and improperly sealed and stored food in the kitchen. During a tour of the facility's kitchen, it was observed that several food items, including buttermilk, coffee creamer, and sour cream, were past their expiration dates. Additionally, an opened and unsealed traditional pie crust was found with freezer burn, indicating improper storage. These findings were confirmed by the Dietary Manager, who acknowledged that expired foods should be removed immediately to prevent potential health risks to residents. Furthermore, the facility did not maintain the freezer temperature at the required level to keep foods solid. An opened, unsealed bag of beef franks was found to be soft and not frozen solid, with a temperature reading of 27.2 degrees Fahrenheit, which is above the recommended 0 degrees Fahrenheit. The Dietary Manager admitted that the freezer temperature might have dropped due to recent cleaning activities. The facility's policies on refrigerated and frozen food storage, which require proper sealing, labeling, and temperature maintenance, were not followed, leading to these deficiencies.
QAA Committee Lacks Required Medical Director Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required members, as the Medical Director had not attended any QAA meetings in over a year. This was confirmed through interviews and a review of the facility's QAA attendance sheets for the past year, which showed the absence of the Medical Director's signature. The QAA committee is required to include the Director of Nursing Services, the Medical Director or their designee, at least three other staff members, and the infection preventionist, with at least one member being in a leadership role such as the administrator, owner, or board member. The deficiency has the potential to affect all 88 residents in the facility, as indicated by the facility's Long-Term Care Facility Application for Medicare and Medicaid.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as observed during a survey. A resident was seen in the hallway with yogurt spilled on her sweatshirt and face. Two staff members, a housekeeper and an LPN, walked past the resident without offering assistance. The housekeeper made a loud comment about the resident's appearance, and the LPN whispered something to the housekeeper, but neither stopped to help clean the resident. The Director of Nursing later acknowledged that the staff should have ensured the resident was presentable and that the incident was a dignity issue. The resident involved is moderately cognitively impaired, with a history of Huntington's disease, and requires substantial assistance with bathing. Her care plan indicates a risk for self-care performance deficits. The facility's policy on dignity emphasizes that residents should be treated with respect and that demeaning practices are prohibited. The policy also states that staff should promote dignity and assist residents, particularly those who are cognitively impaired.
Failure to Provide SNFABN to Residents Discharged from Medicare Part A
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) Form CMS-1005 to residents who were discharged from Medicare Part A services with benefit days remaining. This deficiency was identified for three residents who were reviewed for Advanced Beneficiary Notice and financial liability. The Business Office Manager (BOM), identified as V11, documented the start and end dates of Medicare Part A skilled services for these residents and noted that the facility initiated the discharge from Medicare Part A services before benefit days were exhausted. However, V11 did not provide the SNFABN to the residents, citing that the Notice of Medicare Non-Coverage (NOMNC) was issued instead. During interviews, V11 stated that she was trained not to give the SNFABN if a NOMNC was issued. Upon reviewing the facility's policy, both V11 and the Administrator, identified as V1, acknowledged that SNFABNs should have been completed for the residents in question. The facility's policy on Notices of Non-coverage and Advanced Beneficiary Notices, revised in October 2024, specifies that the SNFABN should be issued prior to the end of Medicare A services to inform residents of potential costs incurred after Medicare coverage ends. The policy also states that the SNFABN should be provided in addition to the NOMNC unless Medicare coverage ends due to exhaustion of the 100 days.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents, their representatives, and the ombudsman regarding the reasons for hospital transfers. This deficiency was identified for three residents during a survey. The administrator admitted that the facility had not been issuing written documentation for hospital transfers, as they were unaware of the requirement. This lack of notification was confirmed through interviews with residents and their family members, as well as a review of the residents' electronic health records, which showed no documentation of written notices being provided. One resident, who had multiple diagnoses including Alzheimer's and schizophrenia, experienced a medical emergency requiring CPR and was subsequently transferred to the hospital. Despite the critical nature of the situation, no written notice was given to the resident or their power of attorney, nor was the ombudsman notified. Similar failures were noted for two other residents who were transferred to the hospital, with no written documentation provided to them, their representatives, or the ombudsman, as confirmed by interviews and record reviews.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification to residents or their representatives regarding the bed-hold policy at the time of transfer to a hospital. This deficiency was observed in three residents who were transferred to the hospital. The facility's policy requires that residents and their representatives be informed in writing about the bed-hold and return policy prior to transfers and therapeutic leaves. However, documentation of this notification was not found in the medical records of the residents involved. One resident, who had multiple diagnoses including Alzheimer's and schizophrenia, was transferred to the hospital after a medical emergency and subsequent stabilization. Despite the critical nature of the transfer, there was no documentation of the bed-hold policy being communicated to the resident or their power of attorney. Similarly, another resident and their brother, who acts as a representative, denied receiving any information about the bed-hold policy when the resident was transferred to the hospital. The third resident also confirmed not being notified of the bed-hold policy upon their transfer. The facility administrator acknowledged that the policy should have been provided to the residents and their representatives.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for three residents who are dependent on staff for assistance with activities of daily living (ADLs). Resident 29 was observed with long, jagged nails with a brown substance underneath and oily hair. Her niece confirmed that the staff needed to cut and clean her nails. Resident 29's electronic health record (EHR) indicated severe cognitive impairment and dependency on staff for personal hygiene. Resident 64 was found with oily hair and excessive facial hair, which had not been shaved for over a month, causing her distress. Her brother confirmed the lack of care, and her care plan indicated a need for assistance with bathing, showering, and nail hygiene due to Parkinson's disease and moderate cognitive impairment. Resident 86 was observed with a brown substance under his nails and stated that he provides his own nail care when given supplies by the staff. His EHR showed moderate cognitive impairment and a need for partial assistance with personal hygiene. The facility's policy on ADLs, revised in March 2018, stated that residents unable to perform ADLs independently should receive necessary services to maintain good grooming and personal hygiene. The facility administrator acknowledged the expectation for staff to provide nail care, remove facial hair, and wash residents' hair to maintain their dignity.
Failure to Apply Anti-Contracture Device as Ordered
Penalty
Summary
The facility failed to ensure that anti-contracture devices were applied to a resident as ordered. This deficiency was observed in a resident with a history of hemiplegia and hemiparesis following a cerebral infarction, affecting the right dominant side, along with muscle weakness, wasting, and atrophy. The resident's electronic medical record indicated a physician's order for a right-hand palm protector to be worn at all times, except during care. However, during observations on two separate occasions, the resident was seen without the palm protector, with the right hand in a fist form, indicating non-compliance with the physician's order. The Restorative Nurse Manager confirmed that the resident was supposed to use the palm protector during the day and remove it at night. Despite this, the palm protector was found in the resident's bedroom dresser rather than being worn. The facility's policy on Assistive Devices and Equipment, revised in July 2017, states that devices and equipment that assist with resident mobility, safety, and independence should be provided for residents. The failure to apply the anti-contracture device as ordered represents a deficiency in adhering to the prescribed care plan for the resident.
Improper Positioning of Catheter Drainage Bag During Wound Care
Penalty
Summary
The facility failed to properly position an indwelling catheter drainage bag during a wound care dressing change for a resident. During the procedure, the Wound Care Nurse Manager and the Memory Care Coordinator unhooked the resident's catheter drainage bag and placed it on the bed while turning the resident to access a sacral wound. After completing the dressing change, the catheter bag was left on the bed under the resident's leg, and it remained there even after the staff left the room. The resident involved has a history of osteomyelitis of the vertebra, a stage 4 pressure ulcer in the sacral region, and neuromuscular dysfunction of the bladder, necessitating the use of an indwelling catheter. The resident's care plan specifies that the catheter bag should be positioned below the level of the bladder to ensure proper urine flow and prevent backflow. The Director of Nursing confirmed that the catheter bag should not have been left on the bed, as it contravenes the facility's policy, which requires the drainage bag to be positioned lower than the bladder at all times.
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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 Kankakee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Miller Health Care Center | 0.5 mi | ★★★★★ | 7 | 1 |
| Arc At Kankakee | 0.5 mi | ★★★★★ | 0 | 0 |
| Citadel Of Bourbonnais,the | 2.2 mi | ★★★★★ | 9 | 0 |
| Arc At Bradley | 2.3 mi | ★★★★★ | 3 | 0 |
| Momence Meadows Nursing & Rehab | 11.5 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.