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Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 97 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
This facility has areas of concern that warrant careful consideration. Registered Nurse hours are 81% of the EveryPlace reference benchmark; ask how RN coverage is allocated across shifts. The latest standard survey recorded 16 findings, above the IL average of 12.0. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.
PA Peterson at the Citadel receives highly polarized feedback, with many families reporting severe neglect, unsanitary conditions, and chronic understaffing. While some patients praise the physical and occupational therapy teams and specific individual nurses, these positive experiences are frequently overshadowed by reports of unresponsive call lights, poor food quality, and facility maintenance issues.
Quality Themes
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Concerns
Rating Trends
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Distribution · 100 analyzed
This facility rarely responds to reviews.
Personalized based on this facility's data
Key Review Excerpts
“They fast tracked my care, I was doing sometype of physical or occupational therapy upwards of two or three times a day, every day. The staff was wonderful, caring, professional.”
“The girls there on the men too let him do that they give him a sense of duty when he would act out they were kind and loving and when he had a fall I was contacted and they stood by the whole time.”
“They would let his colostomy bag burst and leave him lie in the waste for hours and it got into his wounds and infected them causing sepsis.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
8
measures
9
measures
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents vaccinated for the flu
Residents on antipsychotic medication
Residents whose walking got worse
Residents vaccinated for pneumonia
Residents who lost too much weight
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
This facility shows concerning patterns with frequent family complaints driving inspections, particularly around medication management, daily care assistance, and infection control. Half of the 67 deficiencies were triggered by complaints, indicating ongoing resident and family concerns about care quality. Issues with medication services and basic care appear repeatedly across multiple surveys, suggesting persistent problems despite reported corrections by the facility.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Federal Penalties
Fine
Jul 10, 2024
$21,212
Pa Peterson at the Citadel
for profit
Citadel Healthcare
13 facilities nationwide
Chain avg rating: 3.1/5 · Rank 10 of 13
Owners
Kohen, Tsipporah
Owner
Key personnel
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