Illinois ›Rockford

The Citadel at Saint Anne Place

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4405 Highcrest Road, Rockford, IL 61107 (opens Google Maps) · Winnebago County · (815) 229-1999· 179 certified beds · avg 125 residents/day · certified since Oct 29, 1986 · Medicare and Medicaid certified

Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →

1/5
Health inspection rating (on-site)
inspected Jun 5, 2025
9
Serious findings on record
most recent Nov 25, 2025
$123,556
Fines, last 3 years
3.03
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

New to these records? How to read an inspection report →

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5 · how star ratings work →

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and quality measures from resident assessments and claims.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, isolated · Nov 25, 2025 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Dec 5, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Jul 8, 2025 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Jul 10, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Jun 5, 2025 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Jul 3, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Jun 5, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Jun 17, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Jun 5, 2025 · F-0692

The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.

Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Jun 17, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Aug 7, 2024 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Aug 14, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Feb 21, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Feb 22, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Nov 15, 2023 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Nov 16, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Jul 13, 2023 · F-0692

The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.

Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Jul 28, 2023 (Deficient, Provider has date of correction)

Inspection findings in the public record

Showing the latest 3 of 44 inspection findings. Open the full record below to read every finding.

  1. D · Potential for more than minimal harm, isolated

    The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint F-0677

  2. D · Potential for more than minimal harm, isolated

    The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. · from a complaint F-0576

  3. D · Potential for more than minimal harm, isolated

    The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint F-0755

View all 44 inspection findingsShow only the latest 3 findings

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.

DateSeverityWhat the facility was cited for
Jun 23, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint · F-0677
Apr 21, 2026D · Potential for more than minimal harm, isolatedThe facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. · from a complaint · F-0576
Apr 14, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755
Dec 16, 2025D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Nov 25, 2025▲ G · Actual harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Nov 25, 2025E · Potential for more than minimal harm, patternThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint · F-0550
Nov 25, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint · F-0686
Nov 25, 2025D · Potential for more than minimal harm, isolatedThe facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint · F-0694
Nov 25, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755
Jul 8, 2025▲ G · Actual harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Jun 5, 2025▲ G · Actual harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686
Jun 5, 2025▲ G · Actual harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Jun 5, 2025▲ G · Actual harm, isolatedThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692
Jun 5, 2025F · Potential for more than minimal harm, widespreadThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812
Jun 5, 2025E · Potential for more than minimal harm, patternThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755
Jun 5, 2025E · Potential for more than minimal harm, patternThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · F-0805
Jun 5, 2025D · Potential for more than minimal harm, isolatedThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · F-0550
Jun 5, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684
Jun 5, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · F-0695
Jun 5, 2025D · Potential for more than minimal harm, isolatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · F-0725
Jun 5, 2025D · Potential for more than minimal harm, isolatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880
Apr 29, 2025D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Aug 7, 2024▲ G · Actual harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686
Aug 7, 2024D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689
Aug 7, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755
Aug 7, 2024D · Potential for more than minimal harm, isolatedThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · F-0758
Aug 7, 2024D · Potential for more than minimal harm, isolatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · F-0759
Aug 7, 2024D · Potential for more than minimal harm, isolatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761
Aug 7, 2024D · Potential for more than minimal harm, isolatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880
Jul 17, 2024D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Apr 3, 2024D · Potential for more than minimal harm, isolatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint · F-0760
Mar 13, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint · F-0697
Mar 13, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755
Feb 21, 2024▲ G · Actual harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Nov 15, 2023▲ G · Actual harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Nov 15, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Jul 13, 2023▲ G · Actual harm, isolatedThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692
Jul 13, 2023D · Potential for more than minimal harm, isolatedThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · F-0550
Jul 13, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684
Jul 13, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686
Jul 13, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · F-0688
Jul 13, 2023D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689
Jul 13, 2023D · Potential for more than minimal harm, isolatedThe facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · F-0693
Jul 13, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (7 → 11).

Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2023
All citations: 10
Serious citations (G–L): 2
2024
All citations: 12
Serious citations (G–L): 2
2025
All citations: 19
Serious citations (G–L): 5
2026
All citations: 3
Serious citations (G–L): 0

All bars start at zero. Exact values and supporting details remain below.

YearCitationsSerious (G–L)Worst severity that year
2023102G ▲
2024122G ▲
2025195G ▲
202630D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

How to file a complaint about care →

5 fines totaling $123,556, plus 1 Medicare payment denial period.

Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.

DateTypeAmount / length
Nov 25, 2025Fine$38,786
Jun 5, 2025Fine$44,372
Jun 5, 2025Payment Denial12 days from Jun 28, 2025
Aug 7, 2024Fine$13,309
Feb 21, 2024Fine$14,050
Nov 15, 2023Fine$13,039

Nurse staffing (from payroll records, adjusted for how much care residents need)

What these staffing numbers mean →

Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilityIllinois averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: 3.03
Illinois average: 2.99
U.S. average: 3.95
Registered Nurse hours
This facility: 0.76
Illinois average: 0.63
U.S. average: 0.69
Weekend total nurse staffing
This facility: 2.61
Illinois average: 2.67
U.S. average: 3.50

All bars start at zero. Exact values and supporting details remain below.

MeasureThis facilityIllinois avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.032.993.95top 31% in Illinois; bottom 15% in the U.S.
Registered Nurse hours0.760.630.69top 24% in Illinois; top 31% in the U.S.
Weekend total nurse staffing2.612.673.50top 36% in Illinois; bottom 13% in the U.S.
Weekend RN hours (not acuity-adjusted)0.570.560.48top 34% in Illinois; top 25% in the U.S.
Total nursing staff turnover (%)62.244.545.8bottom 11% in Illinois; bottom 13% in the U.S.
RN turnover (%)59.041.842.9bottom 21% in Illinois; bottom 23% in the U.S.

Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.42, RN 0.85, weekend 2.94.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.42 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 2/5.

Quality measures: assessments & claims

Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.

Quality measures rating: 1/5 · long-stay residents: 2/5 · short-stay residents: 1/5

Costs & payment

Price evidence · separate from quality

No verified facility-specific private-pay price is available in our data for The Citadel at Saint Anne Place. CMS inspection and staffing records do not tell us what this home will charge you.

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Who owns this facility

How to read ownership records →

Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →

Non profit - Church related

Owner / managerTypeRoleStakeSince
Ownership Data Not Available

All 1 owning or managing party CMS has on file are shown — none excluded.

Questions to ask on your visit

Full visit checklist →

Print visit checklist

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

  • "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
  • "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
  • "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
  • "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
  • "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
  • "How can my family member make private phone or video calls, and can we see where?"
  • "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
  • "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"

Also worth asking anywhere

  • "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
  • "Can I see the plan of correction for the findings in your most recent state inspection?"
  • "CMS reports 62% total nursing staff turnover here — who on the care team has been with you longest?"
  • "Can I visit again unannounced, at a mealtime or on a weekend?"

Nearby facilities (12 closest of 20 within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Pa Peterson at the Citadel1.4 miRockford, IL★☆☆☆☆2/5abuse
Alden Park Strathmoor1.7 miRockford, IL★☆☆☆☆2/5
Fairhaven Christian Ret Center1.7 miRockford, IL★★★☆☆3/5
Forest City Rehab & Nrsg Ctr1.9 miRockford, IL★☆☆☆☆1/5
Alpine Fireside Health Center2.0 miRockford, IL★★★☆☆3/5
Alden Debes Rehab & HCC2.2 miRockford, IL★☆☆☆☆2/5abuse
Rock River Health Care2.9 miRockford, IL★★★☆☆3/5
Avira Health Pavilion2.9 miLoves Park, IL★★★★☆4/5
Amberwood Care Centre3.5 miRockford, IL★★★☆☆4/5
Mercyhealth Javon Bea Hospital -SNF3.5 miRockford, IL★★★★☆5/5
River Bluff Nursing Home3.5 miRockford, IL★★☆☆☆2/5
Willows Health Center4.0 miRockford, IL★★★☆☆3/5

Compare this facility with the 3 closest →

Other facilities in the same county

CMS records place this facility in Winnebago, IL — 15 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.

Listed by facility name — not a ranking. Homes already in the table above are not repeated here.

All facilities in Rockford →

Facility data as of CMS processing date 2026-08-01. CCN 145563.

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