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TheVardellReport
The Citadel at Saint Anne Place
Skilled nursing facility and nursing facility
4405 Highcrest Road
Rockford, IL 61107
Report
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The Vardell Report.The Citadel at Saint Anne Place
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Rockford, IL
- Record Period
- 2023–2026
- Source Documents
- 17
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 15 inspections from July 2023 to June 2026, state surveyors documented 44 findings at The Citadel at Saint Anne Place; 44 have a recorded correction; CMS lists 6 enforcement actions in the window.
- Inspections
- 15
- 2023–2026, complaint and standard
- Findings
- 44
- Deficiencies cited by state inspectors
- Corrected
- 44
- Of 44 findings, with a recorded correction date
- Penalties
- 6
- 5 fines; payment not published, 1 closed
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 2 | 10 | 2 |
| 2024 | 5 | 12 | 2 |
| 2025 | 5 | 19 | 5 |
| 2026 | 3 | 3 | 0 |
What the Record Shows
- 44 of 44 findings have a recorded correction date.
- CMS lists 6 enforcement actions in the window: 5 fines totaling $123,556, their payment not published; denial of payment imposed June 5, 2025, ended July 10, 2025.
- 13 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, June 5, 2025, recorded 11 findings (most serious: Level G).
What to Ask About
- Accident Hazards and Supervision, Cited in Eight Inspections
- Quality of Care, Cited in Five Inspections
- Pharmacy Services, Cited in Five Inspections
- Pressure Injury Care, Cited in Four Inspections
- Dignity and Resident Rights, Cited in Three Inspections
- Nutrition and Hydration, Cited in Two Inspections
- Infection Control, Cited in Two Inspections
Report at a Glance
- Facility
- The Citadel at Saint Anne Place
- Address
- 4405 Highcrest Road, Rockford, IL 61107
- CMS Certification Number
- 145563
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 179
- Ownership
- Non profit - Church related
- Record Window
- July 13, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
1 finding
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jun 26, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
1 finding
- F576Ensure residents have reasonable access to and privacy in their use of communication methods.Level DNo actual harm, potential for moreCorrected Apr 23, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
1 finding
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Apr 17, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Dec 18, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
5 findings
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Dec 5, 2025
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Dec 5, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Dec 5, 2025
- F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Level DNo actual harm, potential for moreCorrected Dec 5, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Nov 26, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Jul 10, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
11 findings
The same visit included a complaint investigation.
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Jul 3, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jun 17, 2025
- F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Jun 17, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Jun 19, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Jun 17, 2025
- F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level ENo actual harm, potential for moreCorrected Jul 1, 2025
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jun 17, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 20, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Jun 17, 2025
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level DNo actual harm, potential for moreCorrected Jun 17, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 2, 2025
Enforcement Action
Civil money penalty, $44,372 imposed June 5, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 5, 2025, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed June 5, 2025. Status: Closed, July 10, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 5, 2025, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $38,786 imposed November 25, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of June 5, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 30, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
7 findings
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Aug 14, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Aug 14, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Aug 14, 2024
- F758Implement 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.Level DNo actual harm, potential for moreCorrected Aug 14, 2024
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Aug 8, 2024
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Aug 8, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Aug 14, 2024
Enforcement Action
Civil money penalty, $13,309 imposed August 7, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 7, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 22, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Apr 10, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 21, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Mar 21, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Feb 22, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
2 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Nov 16, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 17, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
8 findings
- F692Provide enough food/fluids to maintain a resident's health.Level GActual harmCorrected Jul 28, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jul 28, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 28, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jul 28, 2023
- F688Provide 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.Level DNo actual harm, potential for moreCorrected Jul 28, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 28, 2023
- F693Ensure 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.Level DNo actual harm, potential for moreCorrected Jul 28, 2023
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Jul 28, 2023
Enforcement Action
Civil money penalty, $13,039 imposed November 15, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 13, 2023, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $14,050 imposed February 21, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of July 13, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Accident Hazards and Supervision, Cited in Eight Inspections
Inspectors cited F689 in July 2023, November 2023, February 2024, July 2024, August 2024, April 2025, June 2025 and December 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424242525252525262626F689 across all 15 inspections, oldest to newest - 2
Quality of Care, Cited in Five Inspections
Inspectors cited F684 in July 2023, November 2023, June 2025, July 2025 and November 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424242525252525262626F684 across all 15 inspections, oldest to newest - 3
Pharmacy Services, Cited in Five Inspections
Inspectors cited F755 in March 2024, August 2024, June 2025, November 2025 and April 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424242525252525262626F755 across all 15 inspections, oldest to newest - 4
Pressure Injury Care, Cited in Four Inspections
Inspectors cited F686 in July 2023, August 2024, June 2025 and November 2025. This citation covers how the home prevents and treats pressure injuries (bedsores). The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424242525252525262626F686 across all 15 inspections, oldest to newest - 5
Dignity and Resident Rights, Cited in Three Inspections
Inspectors cited F550 in July 2023, June 2025 and November 2025. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424242525252525262626F550 across all 15 inspections, oldest to newest - 6
Nutrition and Hydration, Cited in Two Inspections
Inspectors cited F692 in July 2023 and June 2025. This citation covers whether residents get enough food and fluids to stay healthy. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424242525252525262626F692 across all 15 inspections, oldest to newest - 7
Infection Control, Cited in Two Inspections
Inspectors cited F880 in August 2024 and June 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242424242525252525262626F880 across all 15 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in eight inspections, most seriously at level G.
- 02
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in five inspections, most seriously at level G.
- 03
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in five inspections, most seriously at level E.
- 04
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in four inspections, most seriously at level G.
- 05
How do staff learn each resident’s preferences, and how is a complaint about dignity handled?
Dignity and Resident Rights: cited in three inspections, most seriously at level E.
- 06
How are weight and fluid intake tracked, and what happens when a resident starts losing weight?
Nutrition and Hydration: cited in two inspections, most seriously at level G.
- 07
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level D.
- 08
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Insufficient nursing staff was cited in June 2025.
- 09
What led to the 2025 fine, and has it been paid?
A $38,786 civil money penalty was imposed November 25, 2025. CMS publishes the fine, not whether it has been paid. The record holds six enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Illinois state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Jul 13, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Nov 15, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Feb 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Mar 13, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Apr 3, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Jul 17, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Aug 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Apr 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Jun 5, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Jul 8, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Nov 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Dec 16, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Apr 14, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Apr 21, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Illinois state survey agency
Inspection Jun 23, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 145563
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowJuly 13, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before July 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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