The Citadel at Saint Anne Place
4405 Highcrest Road · Rockford, IL · 61107 · 8152291999
179 certified beds Non profit - Church related
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $117,351 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
- 9 citations involved actual harm to residents.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
5 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$117,351 in federal fines in the last 24 months
3 fines — CMS fines are reserved for verified, serious non-compliance.
63% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 3.35 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.83 | 0.55–0.75 |
| Weekend hours / resident-day | 2.70 | ≈ weekday level |
| Nursing turnover / year | 63% | median 45% |
| Fines (3-yr window) | 6 · $162,728 |
Inspection citations (43 in the current record)
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Potential for harm · D April 21, 2026 · found via complaint
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected April 23, 2026 · Resident Rights
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Potential for harm · D April 14, 2026 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 17, 2026 · Pharmacy Service
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Potential for harm · D December 16, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 18, 2025 · Quality of Life and Care
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Actual harm · G November 25, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 5, 2025 · Quality of Life and Care
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Potential for harm · E November 25, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected December 5, 2025 · Resident Rights
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Potential for harm · D November 25, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected December 5, 2025 · Quality of Life and Care
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Potential for harm · D November 25, 2025 · found via complaint
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected December 5, 2025 · Quality of Life and Care
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Potential for harm · D November 25, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected November 26, 2025 · Pharmacy Service
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Actual harm · G July 8, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 10, 2025 · Quality of Life and Care
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Actual harm · G June 5, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected July 3, 2025 · Quality of Life and Care
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Actual harm · G June 5, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected June 17, 2025 · Quality of Life and Care
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Actual harm · G June 5, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected June 17, 2025 · Quality of Life and Care
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Potential for harm · D June 5, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected June 17, 2025 · Resident Rights
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Potential for harm · D June 5, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected June 20, 2025 · Quality of Life and Care
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Potential for harm · D June 5, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected June 17, 2025 · Quality of Life and Care
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Potential for harm · D June 5, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected June 17, 2025 · Nursing and Physician Services
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Potential for harm · E June 5, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected June 17, 2025 · Pharmacy Service
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Potential for harm · E June 5, 2025
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected July 1, 2025 · Nutrition and Dietary
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Potential for harm · F June 5, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected June 19, 2025 · Nutrition and Dietary
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Potential for harm · D June 5, 2025
Provide and implement an infection prevention and control program.
Corrected July 2, 2025 · Infection Control
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Potential for harm · D April 29, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 30, 2025 · Quality of Life and Care
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Actual harm · G August 7, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected August 14, 2024 · Quality of Life and Care
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Potential for harm · D August 7, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 14, 2024 · Quality of Life and Care
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Potential for harm · D August 7, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected August 14, 2024 · Pharmacy Service
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Potential for harm · D August 7, 2024
Implement 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.
Corrected August 14, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| November 25, 2025 | Fine | $59,670 |
| June 5, 2025 | Fine | $44,372 |
| June 5, 2025 | Payment Denial | 12 days |
| August 7, 2024 | Fine | $13,309 |
| February 21, 2024 | Fine | $14,050 |
| November 15, 2023 | Fine | $13,039 |
| July 13, 2023 | Fine | $18,288 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145563 · certified since October 29, 1986. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.