
Report
TheVardellReport
The Citadel at Saint Joseph Village
Skilled nursing facility and nursing facility
659 East Jefferson Street
Freeport, IL 61032

TheVardellReport
Skilled nursing facility and nursing facility
659 East Jefferson Street
Freeport, IL 61032
Life by Vardell Presents
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Across 19 inspections from October 2023 to April 2026, state surveyors documented 53 findings at The Citadel at Saint Joseph Village; 53 have a recorded correction; CMS lists 7 enforcement actions in the window.
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 3 | 3 | 0 |
| 2024 | 6 | 21 | 4 |
| 2025 | 7 | 12 | 2 |
| 2026 | 3 | 17 | 0 |
Chronology
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.
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
14 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
4 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
7 findings
Enforcement Action
Civil money penalty, $15,004 imposed December 11, 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 December 11, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $14,731 imposed March 18, 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 December 11, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $15,015 imposed September 2, 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 December 11, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
8 findings
The same visit included a complaint investigation.
Enforcement Action
Civil money penalty, $56,245 imposed February 8, 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 February 8, 2024, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed February 8, 2024. Status: Closed, March 13, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 8, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $12,248 imposed August 1, 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 February 8, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $12,581 imposed September 13, 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 February 8, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
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
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
Inspectors cited F689 in February 2024, August 2024, September 2024, December 2024, March 2025, September 2025 and March 2026. 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.
Inspectors cited F684 in August 2024, May 2025, June 2025, July 2025 and March 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. 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.
Inspectors cited F550 in February 2024, December 2024, July 2025 and March 2026. 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.
Inspectors cited F755 in February 2024, May 2025, June 2025 and March 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.
Inspectors cited F686 in February 2024 and May 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.
Inspectors cited F690 in February 2024 and March 2026. This citation covers continence care, catheter care and preventing urinary tract infections. 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.
Inspectors cited F694 in December 2024 and March 2026. The agency describes it this way: Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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.
Inspectors cited F695 in February 2024 and March 2026. This citation covers oxygen, breathing treatments and other respiratory care. 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.
Inspectors cited F759 in December 2024 and March 2026. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. 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.
Inspectors cited F760 in October 2023 and December 2024. This citation covers whether residents are free from significant medication errors. 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.
Inspectors cited F805 in December 2024 and March 2026. The agency describes it this way: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. 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.
Inspectors cited F812 in December 2024 and March 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F880 in February 2024 and March 2026. 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.
For Your Next Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
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 seven inspections, most seriously at level G.
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 E.
How do staff learn each resident’s preferences, and how is a complaint about dignity handled?
Dignity and Resident Rights: cited in four inspections, most seriously at level E.
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in four inspections, most seriously at level E.
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in two inspections, most seriously at level G.
How is continence care scheduled, and how do you prevent urinary infections?
Continence and Catheter Care: cited in two inspections, most seriously at level D.
What changed after F694 was cited, and how do you check it now?
Citation F694: cited in two inspections, most seriously at level G.
Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?
Respiratory Care: cited in two inspections, most seriously at level D.
How are medication passes checked, and what happens when an error is found?
Medication Error Rate: cited in two inspections, most seriously at level E.
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in two inspections, most seriously at level D.
What changed after F805 was cited, and how do you check it now?
Citation F805: cited in two inspections, most seriously at level E.
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level F.
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.
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
What led to the 2025 fine, and has it been paid?
A $15,015 civil money penalty was imposed September 2, 2025. CMS publishes the fine, not whether it has been paid. The record holds seven enforcement actions in the window.
The Evidence
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Illinois state survey agency.
Illinois state survey agency
Inspection Oct 10, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Nov 1, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Nov 9, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Feb 8, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Apr 23, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection May 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Aug 1, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Sep 13, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Dec 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Mar 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection May 28, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Jun 10, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Jun 13, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Jul 21, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Sep 2, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Dec 6, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Mar 5, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Mar 12, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Apr 22, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services · 145935
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Record windowOctober 10, 2023 – October 1, 2026
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.