The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited November 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 684 — 42 CFR §483.25 — S/S: G
Nursing home report
The Citadel at Saint Anne Place
ROCKFORD, IL · Medicare-certified · 179 beds
Needs attention
Non-profit
1 of 5 overall
The Citadel at Saint Anne Place in Rockford, IL has a 1-star overall rating, with 1-star health inspection and quality ratings and 2-star staffing. Reported nurse staffing is 3.35 hours per resident per day, below the federal benchmark of 4.1, and the facility had $141,244 in fines in the last 24 months plus a recent federal penalty.
Facility ratings
Health inspections
Staffing
3.3456 hrs/resident/day
Quality measures
Last inspection: December 16, 2025Penalties, last 24 months: $141,244recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.3456.
Staffing detail
- Registered nurses
- 0.83
- Licensed practical nurses
- 0.69
- Nurse aides
- 1.82
- Weekend nursing
- 2.70
Hours per resident per day.
Total staff turnover: 63%
Registered nurse turnover: 62%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
20.7%14.3%Improving
Residents with a fall causing major injury
4.5%6.2%Worsening
Residents with pressure ulcers (bedsores)
11.6%7.3%Improving
Residents with a urinary tract infection
3.4%3.2%No change
Residents who lost too much weight
2.4%10.6%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
25%29.1%Worsening
Residents whose ability to walk got worse
—31.2%—
Long-stay residents on antianxiety or sleep medication
19.3%20.9%Worsening
Short-stay residents newly given an antipsychotic
1.2%0.8%No change
Residents with a long-term catheter
3.3%0.8%Improving
Residents with new or worsening incontinence
13.2%38.2%Worsening
Residents with depressive symptoms
4.5%7.7%Worsening
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—96%—
Long-stay residents given the pneumonia vaccine
91%60.4%Worsening
Short-stay residents given the seasonal flu vaccine
—72.5%—
Short-stay residents given the pneumonia vaccine
82.4%49.8%Worsening
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited June 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited June 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
The home failed to provide enough food and fluids to keep residents healthy. Cited June 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 692 — 42 CFR §483.25(g) — S/S: G
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited June 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal fine of $59,670 was recorded.
- INSPECTION
Health inspection found 5 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal payment denial was recorded.
- PENALTY
A federal fine of $68,265 was recorded.
- PENALTY
A federal fine of $13,309 was recorded.
Penalties & enforcement
On record with Medicare: 6 fines · $186,621 in total fines · 1 payment denial.
- $59,670
Federal fine
Nov 25, 2025
- 12 days
Medicare/Medicaid payment denial
Jun 5, 2025
- $68,265
Federal fine
Jun 5, 2025
- $13,309
Federal fine
Aug 7, 2024
- $14,050
Federal fine
Feb 21, 2024
- $13,039
Federal fine
Nov 15, 2023
- $18,288
Federal fine
Jul 13, 2023
Operator & ownership
- Ownership
- Non profit - Church related
- Occupancy
- 127.2 residents on an average day (71% of 179 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 39 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.