Below 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 Of Sterling,the during CMS and state inspections, most recent first.
A resident admitted with lung cancer and pneumonia did not receive the ordered physical therapy services due to scheduling issues and lack of awareness of discharge instructions. The facility's Director of Rehab and DON acknowledged the oversight, which led to the deficiency.
The facility failed to ensure timely notification of a dietitian and implementation of dietary recommendations for residents experiencing severe weight loss. One resident experienced a 13.4% weight loss in one month, with a 15-day delay in starting a recommended dietary supplement. Another resident had a 12.50% weight loss over 14 days, with no weekly weights or new interventions in place. A third resident experienced a 5.4% weight loss in one month, with the facility not following the dietitian's recommendation for weekly weights.
The facility failed to ensure residents were treated with dignity, affecting four residents. One resident was left without assistance to eat during a meal, while others were being fed. Additionally, the Memory Care Director was observed standing while feeding two residents, and a CNA referred to residents needing feeding assistance as 'feeders,' which the DON acknowledged as a dignity issue.
A resident who requires extensive assistance was not properly assisted with hand hygiene after a bowel movement. CNAs cleaned the resident's hands with a washcloth but did not remove all stool from under her fingernails or use soap, and the resident was taken to lunch with a brown/black substance under her fingernails. The resident's care plan did not address her dependence on staff for ADLs.
The facility failed to ensure proper treatments for two residents with pressure injuries. One resident had a stage 4 sacral wound with a loose dressing that was not changed as required, while another resident had a stage 3 coccyx wound without any dressing in place on multiple occasions. These deficiencies were observed despite clear care plans and directives from the wound care nurse.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to provide physical therapy services to a resident as ordered, resulting in a deficiency. The resident, a female with diagnoses of lung cancer and pneumonia, was admitted to the facility with hospital discharge instructions to receive physical therapy services 1-2 times per day, Monday through Friday. Despite these instructions and a physician's order for evaluation and treatment by physical therapy, the resident did not receive any physical therapy services during her stay. Instead, she only received occupational therapy, which was not sufficient for her needs as she expressed a desire to get stronger to return home. The Director of Rehab acknowledged that the resident had not been assessed by a physical therapist due to scheduling issues, as therapists were available on an as-needed basis. The Director of Rehab was unaware of the resident's hospital discharge instructions, which contributed to the oversight. The Director of Nursing admitted that the facility failed to ensure the resident was evaluated by a physical therapist, which was a lapse in following the facility's policies on functional impairment and scheduling therapy services.
Failure to Address Severe Weight Loss in Residents
Penalty
Summary
The facility failed to ensure timely notification of a dietitian and implementation of dietary recommendations for residents experiencing severe weight loss. Resident R27 experienced a 13.4% weight loss in one month, and although the dietitian recommended a dietary supplement on 10/12/23, the supplement was not started until 10/19/23, 15 days after the weight loss was identified. Both the dietitian and the dietary manager were new to their roles and could not explain the delay in addressing R27's weight loss, despite the resident being at risk for unplanned weight loss as noted in their care plan. Resident R339, with multiple diagnoses including chronic obstructive pulmonary disease and dementia, experienced a 12.50% weight loss over 14 days. The dietitian had recommended weekly weights and a dietary supplement, but the facility did not follow these recommendations. The resident had not been weighed weekly, and no new orders or interventions were in place following the significant weight loss. The dietitian was aware of the weight loss but had not implemented any interventions due to the lack of a re-weigh. Resident R61 experienced a 5.4% weight loss in one month. The dietitian had recommended weekly weights following a hospitalization, but the facility did not follow this recommendation. The resident's care plan indicated that significant weight loss should be reported to the nurse, physician, dietary manager, and dietitian, but this protocol was not followed. The Director of Nursing acknowledged that the dietitian's recommendations should be followed for residents experiencing weight loss.
Failure to Ensure Resident Dignity During Meal Times
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner, affecting four residents. During the noon meal on June 11, 2024, one resident was observed sitting in her reclining wheelchair with her meal in front of her, but no one was assisting her to eat, while other residents at her table were being fed or could feed themselves. Additionally, the Memory Care Director was observed standing while feeding two residents, which is not in line with the facility's dignity policy that emphasizes treating residents with respect and promoting their sense of well-being. On June 10, 2024, a Certified Nursing Assistant (CNA) referred to residents requiring feeding assistance as 'feeders,' which was acknowledged by the Director of Nursing as a dignity issue. The facility's Quality of Life - Dignity policy, reviewed in February 2020, states that residents should be treated with dignity and respect at all times, including being addressed by their name of choice and not being labeled by their care needs. These observations indicate a failure to adhere to the facility's policies on resident dignity and respect.
Failure to Assist Resident with Hand Hygiene After Bowel Movement
Penalty
Summary
The facility failed to ensure a resident who requires extensive assistance was properly assisted with washing her hands after having a bowel movement. On June 10, 2024, two CNAs were observed getting the resident out of bed for lunch. The resident had stool on her right hand and leg, indicating she had placed her hand in the stool. The CNAs cleaned the resident's hands with a washcloth but did not remove all the stool from under her fingernails or use soap. They then placed the resident in her wheelchair and took her to lunch without thoroughly washing her hands. The resident had a brown/black substance under her fingernails and around her nail bed. The following day, the resident was observed in the dining room with the same brown/black substance under her fingernails, and she was seen scratching her face and head with her right hand. The resident's Minimum Data Set indicated she is not cognitively intact and is dependent on staff for personal hygiene and toileting hygiene. Additionally, the resident's care plan did not address her dependence on staff for ADLs, despite her decreased eating skills and reliance on staff for personal hygiene. The facility's policy on ADLs, dated March 2018, states that residents unable to carry out ADLs independently will receive necessary services to maintain good nutrition, grooming, and personal hygiene.
Failure to Ensure Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper treatments were in place for residents with pressure injuries. For Resident 68, a stage 4 sacral wound was observed with a loose dressing that had not been changed as per the physician's order. Despite the wound care nurse's directive that dressings should be checked and changed as needed, the dressing was not changed until 10 hours later. The resident's care plan indicated the need for wound management due to decreased mobility, incontinence, and end-of-life care, but these interventions were not adequately followed, leading to the deficiency observed by the surveyors. For Resident 64, a stage 3 wound on the coccyx was noted without any dressing in place on multiple occasions. The wound care nurse confirmed that there should have been an order to monitor and change the dressing every shift, but this was not done. The resident's care plan highlighted the risk of impaired skin integrity due to advanced age, decreased mobility, and dementia, and specified that dressings should be monitored during peri care. However, the lack of adherence to these guidelines resulted in the observed deficiency.
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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 Sterling
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allure Of Sterling | 0.4 mi | ★★★★★ | 15 | 1 |
| La Bella Of Sterling | 1.2 mi | ★★★★★ | 2 | 0 |
| Rock Falls Rehab & Hlth Care C | 2.5 mi | — | 0 | 0 |
| Heritage Square | 11.3 mi | ★★★★★ | 9 | 0 |
| Dixon Rehab & Hcc | 11.8 mi | ★★★★★ | 0 | 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.