3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
21 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Niles, IL
4-star overall rating with 4-star inspections with $64,531 in total fines with 3 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
6930 West Touhy Avenue, Niles, IL
(847) 647-0003
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
99
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Citadel Healthcare
Operator or chain grouping
Approved since
1992-08-01
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
RN hours / resident day
1.08
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.37
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
3.77
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.88
CMS adjusted RN staffing hours
Adjusted total hours
3.08
CMS adjusted total nurse staffing hours
Case-mix index
1.67
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Program rank
12,506
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 18.58% · Performance 24.99% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.12% · Performance 9.40% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.57
Baseline 43.94% · Performance 53.16% · Measure score 2.57 · Achievement 2.57 · Improvement 0
Adjusted total nurse staffing
2.19
Baseline 3.53 hours · Performance 3.7 hours · Measure score 2.19 · Achievement 2.19 · Improvement 0.25
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.43% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 228 · Observed rate 9.65% · Lower 95% interval 7.23% |
| Discharge to community | 53.59% |
50.57%
3 pts better
|
No Different than the National Rate · Eligible stays 241 · Observed rate 45.64% · Lower 95% interval 46.21% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.8% |
95.27%
3.5 pts better
|
Numerator 164 · Denominator 166 |
| Falls with major injury | 2.41% |
0.77%
1.6 pts worse
|
Numerator 4 · Denominator 166 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 50 · Denominator 100 |
| Discharge mobility score | 44% |
50.94%
6.9 pts worse
|
Numerator 44 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 1.81% |
2.29%
0.5 pts better
|
Numerator 3 · Denominator 166 · Adjusted rate 1.81% |
| Healthcare-associated infections requiring hospitalization | 9.4% |
7.12%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 160 · Observed rate 11.25% · Lower 95% interval 6.73% |
| Staff COVID-19 vaccination coverage | 13.89% |
8.2%
5.7 pts better
|
Numerator 15 · Denominator 108 |
| Staff flu vaccination coverage | 80.99% |
42%
39 pts better
|
Numerator 115 · Denominator 142 |
| Discharge function score | 46% |
56.45%
10.5 pts worse
|
Numerator 46 · Denominator 100 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 53 · Denominator 53 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 78 · Denominator 78 |
| Resident COVID-19 vaccinations up to date | 26.14% |
25.2%
0.9 pts better
|
Numerator 23 · Denominator 88 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.0
1.1 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.1 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.3
1.2 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
89.6%
1.5 pts better
|
93.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.2% · Q3 98.5% · Q4 72.9% · 4Q avg 91.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
91.6%
5.6 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.3%
1.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 3.1% · Q4 1.4% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 66.4% |
50.3%
16.1 pts worse
|
11.4%
55 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 61.4% · Q3 90.0% · Q4 92.1% · 4Q avg 66.4% |
| Percentage of long-stay residents who lose too much weight | 10.1% |
6.5%
3.6 pts worse
|
5.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 14.8% · Q3 10.3% · Q4 7.7% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.7% |
18.5%
2.8 pts better
|
19.6%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 17.7% · Q3 19.0% · Q4 12.1% · 4Q avg 15.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.1% |
22.8%
2.7 pts better
|
16.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 24.0% · Q3 20.0% · Q4 20.0% · 4Q avg 20.1% · 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 | 19.3% |
17.2%
2.1 pts worse
|
16.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.3% |
15.0%
3.3 pts worse
|
14.9%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.8% · Q2 17.2% · Q3 12.1% · Q4 10.0% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.1%
0.8 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
21.3%
1 pts worse
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 27.1% · Q3 20.1% · Q4 19.1% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
5.2%
0.2 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 3.9% · Q3 3.5% · Q4 5.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.4% |
68.8%
12.6 pts better
|
81.7%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 92.1% · Q2 82.1% · Q3 75.6% · Q4 74.0% · 4Q avg 81.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
14.0%
3.9 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 9.9% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
2.3%
1.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.2% · Q3 0.0% · Q4 1.4% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.6% |
63.0%
23.6 pts better
|
79.7%
6.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.4% |
26.2%
5.2 pts worse
|
23.9%
7.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.4% · Observed 31.6% · Expected 24.0% · Used in QM five-star |
Survey summary
Top issue: Nutrition and Dietary (1 deficiency)
21 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-07-08
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-07-08
Fire Safety
Use approved construction type or materials.
Corrected 2025-07-08
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 2025-07-08
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-08
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-07-08
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-08
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-08
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-08
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-08
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-07-08
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-07-08
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-07-08
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-07-08
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-07-08
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-08
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-08
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-08
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-07-08
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-08
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-06-13
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-06-13
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-06-13
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-13
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-13
Fire Safety
Install proper backup exit lighting.
Corrected 2024-06-13
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-06-13
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-13
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-13
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-13
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-06-13
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-30
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-13
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-13
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-13
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-06-13
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 2024-06-13
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-13
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-06-13
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-08
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-04-11
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-08
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-11
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-04-11
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-05
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-05-08
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-08
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-05-08
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-05-08
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-08
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-02
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-08
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 2023-05-08
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-11
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-05-08
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-08
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-18
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-13
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-02-13
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-23
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-26
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 2024-06-10
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-06-10
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-10
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-06
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-17
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-03-29
Penalties and ownership
Fine · fine $29,660
Fine
Fine · fine $34,871
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Niles, IL
2-star overall rating with 2-star inspections with $234,006 in total fines with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Niles, IL
4-star overall rating with 4-star inspections with $29,754 in total fines with 4 recent health deficiencies
Niles, IL
5-star overall rating with 4-star inspections with $50,089 in total fines with 4 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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