Cycle 1
Health 2024-12-11 · Fire 2024-12-11
19 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Freeport, IL
The Citadel at Saint Joseph Village
2-star overall rating with 2-star inspections with $110,367 in total fines with 19 recent health deficiencies
659 East Jefferson Street, Freeport, IL
(815) 232-6181
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
78
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ascension Living
Operator or chain grouping
Approved since
1997-03-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 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
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,907
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.69
Baseline 18.65% · Performance 19.72% · Measure score 3.69 · Achievement 3.69 · Improvement 0
Healthcare-associated infections
0.82
Baseline 5.44% · Performance 7.59% · Measure score 0.82 · Achievement 0.82 · Improvement 0
Total nurse turnover
0.66
Baseline 36.99% · Performance 61.00% · Measure score 0.66 · Achievement 0.66 · Improvement 0
Adjusted total nurse staffing
2.30
Baseline 3.56 hours · Performance 3.73 hours · Measure score 2.30 · Achievement 2.30 · Improvement 0.28
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.79% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 107 · Observed rate 12.15% · Lower 95% interval 7.54% |
| Discharge to community | 58.62% |
50.57%
8 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 59.26% · Lower 95% interval 50.44% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 56 · Denominator 56 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 56 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 28 · Denominator 44 |
| Discharge mobility score | 29.55% |
50.94%
21.4 pts worse
|
Numerator 13 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 56 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.59% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 6.78% · Lower 95% interval 4.57% |
| Staff COVID-19 vaccination coverage | 2.41% |
8.2%
5.8 pts worse
|
Numerator 2 · Denominator 83 |
| Staff flu vaccination coverage | 60.19% |
42%
18.2 pts better
|
Numerator 62 · Denominator 103 |
| Discharge function score | 36.36% |
56.45%
20.1 pts worse
|
Numerator 16 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.55% |
96.28%
0.3 pts better
|
Numerator 28 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 53.57% |
25.2%
28.4 pts better
|
Numerator 15 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
89.6%
7.4 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 97.4% · Q3 94.4% · Q4 98.6% · 4Q avg 97.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.1% |
91.6%
3.5 pts worse
|
95.5%
7.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 1.4% · Q4 2.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
50.3%
49.9 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
6.5%
3.8 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.0% · Q3 4.8% · Q4 1.6% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.3% |
18.5%
5.2 pts better
|
19.6%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 11.6% · Q3 11.1% · Q4 11.3% · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.1% |
22.8%
14.7 pts better
|
16.7%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 11.1% · Q3 7.8% · Q4 3.9% · 4Q avg 8.1% · 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 | 13.6% |
17.2%
3.6 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 19.0% · Q3 15.8% · Q4 9.9% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
15.0%
4 pts better
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 22.1% · Q3 10.0% · Q4 6.7% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.1%
0.6 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.6% |
21.3%
0.7 pts better
|
19.8%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 20.4% · Q3 15.5% · Q4 21.7% · 4Q avg 20.6% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.2%
0.8 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 6.9% · Q3 5.5% · Q4 2.8% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.8% |
68.8%
14 pts better
|
81.7%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 82.0% · Q3 73.3% · Q4 79.1% · 4Q avg 82.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.8% |
14.0%
4.8 pts worse
|
12.0%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 17.0% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
2.3%
1.1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.7% · Q4 1.7% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.6% |
63.0%
9.6 pts better
|
79.7%
7.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.7% |
26.2%
9.5 pts better
|
23.9%
7.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 14.9% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
14 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-29 · Fire 2023-03-29
16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-06
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-12-12
G · Actual harm
2025-09-02
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 2025-09-08
D · Potential for more than minimal harm
2025-07-21
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 2025-07-29
D · Potential for more than minimal harm
2025-07-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-07-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-06-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-06-10
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 2025-07-03
E · Potential for more than minimal harm
2025-05-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-05-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-05-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-05-28
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 2025-07-03
G · Actual harm
2025-03-18
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 2025-03-08
G · Actual harm
2024-12-11
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-12-11
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 2024-12-18
E · Potential for more than minimal harm
2024-12-11
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 2024-12-18
D · Potential for more than minimal harm
2024-12-11
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 2024-12-18
D · Potential for more than minimal harm
2024-12-11
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 2024-12-18
D · Potential for more than minimal harm
2024-12-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-12-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-18
G · Actual harm
2024-09-13
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 2024-09-24
D · Potential for more than minimal harm
2024-09-13
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-09-24
G · Actual harm
2024-08-01
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 2024-08-09
D · Potential for more than minimal harm
2024-08-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-05-21
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-04-23
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-05-01
G · Actual harm
2024-02-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-13
D · Potential for more than minimal harm
2024-02-08
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 2024-03-04
D · Potential for more than minimal harm
2024-02-08
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-08
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 2024-03-04
D · Potential for more than minimal harm
2024-02-08
F690 · Quality of Life and Care Deficiencies
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 2024-03-04
D · Potential for more than minimal harm
2024-02-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-08
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 2024-03-04
D · Potential for more than minimal harm
2024-02-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-04
D · Potential for more than minimal harm
2023-11-09
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-11-23
D · Potential for more than minimal harm
2023-11-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-27
G · Actual harm
2023-07-06
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 2023-07-31
E · Potential for more than minimal harm
2023-05-10
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-06-06
F · Potential for more than minimal harm
2023-03-29
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 2023-04-22
D · Potential for more than minimal harm
2023-03-29
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-04-22
D · Potential for more than minimal harm
2023-03-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-22
D · Potential for more than minimal harm
2023-03-29
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 2023-04-22
D · Potential for more than minimal harm
2023-03-29
F690 · Quality of Life and Care Deficiencies
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 2023-04-22
D · Potential for more than minimal harm
2023-03-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-22
D · Potential for more than minimal harm
2023-03-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-22
D · Potential for more than minimal harm
2023-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-22
D · Potential for more than minimal harm
2023-03-22
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 2023-04-10
D · Potential for more than minimal harm
2023-03-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-10
D · Potential for more than minimal harm
2023-03-09
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 2023-04-05
Penalties and ownership
What sits behind the stars
$14,505
2025-03-18
Fine
Fine · fine $14,505
Fine
$14,788
2024-12-11
Fine
Fine · fine $14,788
Fine
$12,581
2024-09-13
Fine
Fine · fine $12,581
Fine
$12,248
2024-08-01
Fine
Fine · fine $12,248
Fine
$56,245
2024-02-08
Fine
Fine · fine $56,245
Fine
$0
2024-02-08
Payment Denial
Payment Denial · denial start 2024-03-09 · 4 days
4 day denial
Ownership
Nearby options
Other facilities in reach
#1
Stephenson Nursing Center
Freeport, IL
3-star overall rating with 3-star inspections with 15 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Pearl Pavilion
Freeport, IL
1-star overall rating with 1-star inspections with $150,091 in total fines with 23 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Manor Court Of Freeport
Freeport, IL
2-star overall rating with 2-star inspections with $88,479 in total fines with 14 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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