The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited September 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
The Citadel at Saint Joseph Village
FREEPORT, IL · Medicare-certified · 124 beds
Needs attention
Non-profitChain member
1 of 5 overall
The Citadel at Saint Joseph Village in Freeport, IL has a 1-star overall rating, with 1-star staffing and 2-star health inspection ratings despite 4-star quality measures. It reports 3.65 nursing hours per resident per day, below the 4.1 federal benchmark, and had $77,664 in fines in the last 24 months, including a recent federal penalty.
Facility ratings
Health inspections
Staffing
3.6517 hrs/resident/day
Quality measures
Last inspection: March 12, 2026Penalties, last 24 months: $77,664recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.6517.
Staffing detail
- Registered nurses
- 0.52
- Licensed practical nurses
- 1.00
- Nurse aides
- 2.13
- Weekend nursing
- 3.10
Hours per resident per day.
Total staff turnover: 61%
Registered nurse turnover: 69%
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
11.8%2.1%Improving
Residents with a fall causing major injury
1.3%7.5%Worsening
Residents with pressure ulcers (bedsores)
6.9%2.4%Improving
Residents with a urinary tract infection
0%0%No change
Residents who lost too much weight
3%10.5%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
22.1%39.3%Worsening
Residents whose ability to walk got worse
19%34.8%Worsening
Long-stay residents on antianxiety or sleep medication
11.6%13.8%Worsening
Short-stay residents newly given an antipsychotic
1.5%1.7%No change
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
20.4%28.1%Worsening
Residents with depressive symptoms
0%35.4%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
—88.1%—
Long-stay residents given the pneumonia vaccine
97.4%95.5%Worsening
Short-stay residents given the seasonal flu vaccine
—72.6%—
Short-stay residents given the pneumonia vaccine
82%84.2%Improving
What the inspectors found
The home failed to ensure IV fluids were given safely and appropriately when needed. Cited December 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 694 — 42 CFR §483.25 — S/S: G
The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited February 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited March 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited March 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 755 — 42 CFR §483.45 — S/S: E
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
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal fine of $23,100 was recorded.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal fine of $14,731 was recorded.
- PENALTY
A federal fine of $15,004 was recorded.
- PENALTY
A federal fine of $12,581 was recorded.
- PENALTY
A federal fine of $12,248 was recorded.
Penalties & enforcement
On record with Medicare: 6 fines · $133,909 in total fines · 1 payment denial.
- $23,100
Federal fine
Sep 2, 2025
- $14,731
Federal fine
Mar 18, 2025
- $15,004
Federal fine
Dec 11, 2024
- $12,581
Federal fine
Sep 13, 2024
- $12,248
Federal fine
Aug 1, 2024
- 4 days
Medicare/Medicaid payment denial
Feb 8, 2024
- $56,245
Federal fine
Feb 8, 2024
Operator & ownership
- Ownership
- Non profit - Corporation
- Chain
- Part of ASCENSION LIVING · 16 homes · 2.9 stars avg
- Occupancy
- 76.7 residents on an average day (62% of 124 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 29 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.