Cycle 1
Health 2025-06-05 · Fire 2025-06-05
19 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Rockford, IL
The Citadel at Saint Anne Place
1-star overall rating with 1-star inspections with $126,951 in total fines with 19 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
4405 Highcrest Road, Rockford, IL
(815) 229-1999
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
179
Certified beds
Average residents
117
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-10-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.14
Registered nurse staffing
LPN hours / resident day
0.72
Licensed practical nurse staffing
Aide hours / resident day
1.88
Nurse aide staffing
Weekend hours
3.45
Weekend nurse staffing
RN turnover
55%
Annual RN turnover
Total nurse turnover
51%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.0
1 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.1% |
89.6%
2.5 pts better
|
93.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.0% |
91.6%
4.4 pts better
|
95.5%
0.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.3%
1.7 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 4.7% |
50.3%
45.6 pts better
|
11.4%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.2% |
6.5%
2.3 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.3% |
18.5%
0.8 pts worse
|
19.6%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
22.8%
4.4 pts better
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 38.0% |
17.2%
20.8 pts worse
|
16.3%
21.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.0% |
15.0%
6 pts worse
|
14.9%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.1%
0.1 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.7%
0.4 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.7% |
21.3%
7.6 pts better
|
19.8%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 9.2% |
5.2%
4 pts worse
|
5.1%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.6% |
68.8%
10.8 pts better
|
81.7%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
14.0%
2.1 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
2.3%
0.8 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.5% |
63.0%
9.5 pts better
|
79.7%
7.2 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.7% |
26.2%
1.5 pts worse
|
23.9%
3.8 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-07 · Fire 2024-08-07
11 health deficiencies
Top issue: Pharmacy Service (6 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2023-07-13 · Fire 2023-07-13
11 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-06-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-06-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-06-05
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-06-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-06-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-06-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-06-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-19
F · Potential for more than minimal harm
2024-08-07
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-09-11
F · Potential for more than minimal harm
2024-08-07
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2024-09-11
F · Potential for more than minimal harm
2024-08-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-07
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-09-11
F · Potential for more than minimal harm
2024-08-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-11
F · Potential for more than minimal harm
2024-08-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-11
E · Potential for more than minimal harm
2024-08-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-11
E · Potential for more than minimal harm
2024-08-07
K222 · Egress Deficiencies
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 2024-09-11
E · Potential for more than minimal harm
2024-08-07
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-09-11
E · Potential for more than minimal harm
2024-08-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-11
E · Potential for more than minimal harm
2024-08-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-11
E · Potential for more than minimal harm
2024-08-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-11
E · Potential for more than minimal harm
2024-08-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-11
F · Potential for more than minimal harm
2023-07-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-09
F · Potential for more than minimal harm
2023-07-13
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-08-03
F · Potential for more than minimal harm
2023-07-13
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-08-03
F · Potential for more than minimal harm
2023-07-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-07-13
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-08-02
F · Potential for more than minimal harm
2023-07-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-01
E · Potential for more than minimal harm
2023-07-13
K222 · Egress Deficiencies
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 2023-08-07
E · Potential for more than minimal harm
2023-07-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-04
E · Potential for more than minimal harm
2023-07-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-07
E · Potential for more than minimal harm
2023-07-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-30
E · Potential for more than minimal harm
2023-07-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-18
G · Actual harm
2025-11-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-11-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-11-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-11-25
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-12-05
D · Potential for more than minimal harm
2025-11-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-11-26
G · Actual harm
2025-07-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-10
G · Actual harm
2025-06-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-03
G · Actual harm
2025-06-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-17
G · Actual harm
2025-06-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-17
F · Potential for more than minimal harm
2025-06-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-19
E · Potential for more than minimal harm
2025-06-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-06-05
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-06-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-06-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-06-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-02
D · Potential for more than minimal harm
2025-04-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-30
G · Actual harm
2024-08-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-08-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-08-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-08-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-08-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-08-07
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-22
D · Potential for more than minimal harm
2024-04-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-03-13
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-03-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-21
G · Actual harm
2024-02-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-22
G · Actual harm
2023-11-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-11-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-17
G · Actual harm
2023-07-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-07-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-07-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-07-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-07-13
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-07-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-07-13
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-07-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-28
Penalties and ownership
What sits behind the stars
$68,265
2025-06-05
Fine
Fine · fine $68,265
Fine
$0
2025-06-05
Payment Denial
Payment Denial · denial start 2025-06-28 · 12 days
12 day denial
$13,309
2024-08-07
Fine
Fine · fine $13,309
Fine
$14,050
2024-02-21
Fine
Fine · fine $14,050
Fine
$13,039
2023-11-15
Fine
Fine · fine $13,039
Fine
$18,288
2023-07-13
Fine
Fine · fine $18,288
Fine
Ownership
Nearby options
Other facilities in reach
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Pa Peterson At The Citadel
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2-star overall rating with 3-star inspections with $21,212 in total fines with 15 recent health deficiencies
#2
Alden Park Strathmoor
Rockford, IL
2-star overall rating with 2-star inspections with $115,265 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Fairhaven Christian Ret Center
Rockford, IL
3-star overall rating with 3-star inspections with $120,225 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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