4405 Highcrest Road, Rockford, IL 61107 · Winnebago County · (815) 229-1999
179 certified beds, about 125 residents a day · Non profit - Church related · Medicare and Medicaid since 1986
CMS Care Compare ratings, data as of September 1, 2026 · CCN 145563 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on June 5, 2025, inspectors cited 11 health deficiencies (the Illinois average is 12.6, the national average 9.2).
Of 44 health citations since July 2023, 9 were rated as actual harm or immediate jeopardy to residents.
CMS lists 5 fines totaling $123,556 in the last three years; the largest was $44,372, and the latest is dated November 25, 2025.
Nurses and nurse aides worked 3.42 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 0.85 of those hours.
62.2% of nursing staff left within the year CMS measured (Illinois average 44.5%).
CMS links it to Citadel Healthcare, an affiliated group of 16 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 44 health citations on file.
Inspectors wroteBased on interview and record review the facility failed to ensure a dependent resident was provided with incontinence care for 2 of 3 residents (R1, R2) reviewed for incontinence care in the sample of 6.
Inspectors wroteBased on interview and record review the facility failed to protect a resident's rights to receive unopened personal package to 1 of 3 residents (R1) reviewed for resident's rights in the sample of 3.
Inspectors wroteBased on observation, interview, and record review the facility failed to administer and accurately document administering a lidocaine patch. This applies to 1 of 3 residents (R1) reviewed for medication administration in the sample of 5.
Inspectors wroteBased on interview and record review the facility failed to transfer a resident in a safe manner for 1 of 3 residents (R1) reviewed for falls in the sample of 3.
Inspectors wroteBased on interview and record review the facility failed ensure a thorough assessment was performed for a resident sustaining a fall and failed to identify an acute fracture prior to sustaining a second fall. This failure resulted in R3 sustaining a fall with x-ray results showing a right hip impacted subcapital fracture of right femoral neck without staff identifying and reporting her injury and sustaining a 2nd fall approximately two days later delaying emergency care and services. This applies to 1 of 3 residents (R3) reviewed for quality of care in the sample size 18.
Inspectors wroteBased on interview and record review the facility failed to ensure residents were treated with dignity by answering call lights in a timely manner. This applies to 4 of 4 residents (R15, R16, R17, R18) reviewed for dignity in the sample of 18.
Inspectors wroteBased on interview and record review the facility failed to initially identify a pressure ulcer and put interventions in place to prevent the area from worsening for a resident at high risk for developing pressure ulcers. This applies to 1 of 3 residents (R5) reviewed for pressure ulcers in the sample of 18.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure sterile catheter dressing changes were performed for a resident with a PICC (Peripherally Inserted Central Catheter) this applies to 1 of 3 residents (R2) reviewed for central lines in the sample of 18.
Inspectors wroteBased on interview and record review the facility failed to administer medications as ordered by the resident's physician. This applies to 1 of 3 residents (R1) reviewed for medication administration in the sample of 13.
Inspectors wroteBased on observation, interview, and record review the facility failed to assess, document, notify the provider, and monitor an injury of unknown origin for 1 of 3 residents (R1) reviewed for quality of care in the sample of 5. This failure resulted in R1 exhibiting signs of an injury (bruising, pain with movement of left arm) for three days before the facility notified the provider and obtained an order for an X-ray. R1's X-ray showed a non-displaced fracture of her left humerus (upper arm).
Inspectors wrote4. R117's face sheet documents she was admitted to the facility on [DATE] with multiple diagnoses including the presence of a stage 3 pressure ulcer to the left buttock, a stage 4 pressure ulcer to the left lower back, stage 3 pressure ulcer to the sacral region, and stage 3 pressure ulcers to the right upper back and left lower back. On 6/4/25 at 10:25 AM, R117 was lying in her bed with an air mattress, and she was positioned onto her right side with pillows. The skin evaluation forms were requested and reviewed and show the first pressure ulcer assessments were completed on 5/8/25. On 6/5/25 at 9:24 AM, V10 RN, said when a resident is admitted with pressure injuries it is the responsibility of the admitting nurse to perform wound assessments and document them in the wound sheets. She said this should be done on the day of admission. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to assist a resident at risk for falls with reaching his urinal (R58), and safely transferring a resident with a mechanical lift (R23 and R2). This failure resulted in R58 falling and obtaining a fractured hip and wrist requiring surgery and hospital stay. The applies to three of eleven residents reviewed for safety in the sample of 59.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate weights were obtained, failed to ensure significant weight loss was identified and reported to the dietitian, and failed to implement dietitian recommendations for 4 of 6 residents (R28, R3, R55, R41) reviewed for nutrition in the sample of 59. This failure resulted in R28 experiencing significant weight loss without the Registered Dietitian being notified.
Inspectors wroteBased on observation, interview, and record review, the facility failed to handle food in a manner to prevent cross-contamination and failed to maintain food preparation equipment in a manner to prevent cross-contamination. This failure has the potential to affect all 131 residents residing in the facility.
Inspectors wroteBased on interview and record review, the facility failed to correctly transcribe a physician's order for 2 residents (R60,R129), failed to ensure the correct dose of a medication was given for 1 resident (R90), failed to ensure the correct medications were given for 1 resident (R25). These failures apply to 4 of 4 residents outside of the sample reviewed for medication errors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to puree peas to a smooth consistency. This applies to 6 of 6 residents (R7, R12, R35, R48, R103, R330) reviewed for altered diets in the sample of 59.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents dependant on staff for cares was treated in a dignified manner, and failed to care for a female resident with facial hair for 3 of 3 residents (R232, R332, R54) reviewed for dignity in sample of 59.
Inspectors wroteThe facility failed to assess and obtain treatment orders for a resident (R86) with two skin tears. This applies to 1 of 2 residents reviewed for non-pressure skin conditions in the sample of 59.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure orders were in place for a resident with a CPAP (Continuous Positive Airway Pressure) and failed to properly clean and store CPAP equipment for 1 of residents (R108) reviewed for respiratory services in the sample of 59.
Inspectors wroteBased on observation, interview and record review the facility failed to answer the residents call light in a timely manner. This applies to three of three residents (R58, R99, R332) in the sample of 59 reviewed for call lights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to wear the appropriate personal protective equipment (PPE) while providing wound care. This applies to 1 of 8 residents (R34) reviewed for infection control in the sample of 59.
Inspectors wroteBased on interview and record review, the facility failed to provide incontinence care in a safe manner that prevented a resident from falling out of bed. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and notify the wound care physician with changes in a pressure injury, and failed to implement pressure relieving intervention to prevent a pressure injury. This applies to 2 of 8 residents (R95 & R100) reviewed for pressure injuries in the sample of 23. These failures resulted in R100's pressure injury deteriorating to an unstageable pressure injury.
Inspectors wroteBased on observation, interview, and record review, the failed to ensure a resident at risk for falls was supervised during toileting, and failed to implement fall prevention interventions for a resident at high risk of falls for 2 of 6 residents (R114, R4) reviewed for safety/supervision in the sample of 23.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a medication as ordered for one of 23 residents reviewed for medications in the sample of 23.
Inspectors wroteBased on interview and record review, the facility failed to ensure as needed anti-anxiety medication had a stop date. This applies to 2 of 5 residents (R4 & R95) reviewed for psychotropic medications in the sample of 23.
Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered. There were 26 opportunities with two errors resulting in a 7.69 % error rate. This applies to two of five residents (R33, R110) observed in the medication pass.
Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of an expired insulin pen, and failed to label an opened insulin pen with an open date for one of 23 residents (R99) reviewed for medication storage in the sample of 23.
Inspectors wroteBased on observation, interview, and record review, the facility failed to donn personal protective equipment (PPE) in an enhanced barrier precaution (EBP) room, and failed to change gloves and perform hand hygiene in a manner to prevent cross contamination for three of 23 residents (R75, R85, R1) reviewed for infection control in the sample of 23.
Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise a resident during medication administration to ensure the resident ingested the medications and did not store them in his room. This applies to 1 of 4 residents (R1) reviewed for safety and supervision in the sample of 4.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free of significant medication errors for 1 of 3 residents (R2) reviewed for medications.
Inspectors wroteBased on interview and record review, the facility failed to manage and treat a resident's pain for 2 or 3 residents (R1, R3) reviewed for pain in the sample of 3.
Inspectors wroteBased on interview and record review, the facility failed to reorder resident medications in at timely manner to ensure residents received their medications as ordered for 2 of 3 residents (R1, R3) reviewed for medication administration in the sample of 3.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was supervised in preparation for a mechanical lift transfer resulting in a fall with injury, and failed to ensure nonslip material was in place in a wheelchair for 2 of 3 residents (R1, R3) reviewed for safety and supervision in the sample of 5. This failure resulted in R3 receiving an acute subdural hematoma along with 2 lacerations with 8 sutures to the left forehead and R1 receiving 14 sutures to the left forehead.
Inspectors wroteBased on interview and record review, the facility failed to provide a safe transfer for a resident. This failure resulted in R1 being transferred without a stand lift device and sustaining a spiral fracture to her right tibia and fibula. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 8.
Inspectors wroteBased on interview and record review, the facility failed to assess and document the cause of a resident's pain and change of condition for 1 of 3 residents (R1) reviewed for pain/change of condition in the sample of 3.
Inspectors wroteBased observation, interview, and record review, the facility failed to monitor a resident's weight who was experiencing weight loss, and failed to provide the ordered follow-up consults with the Dietician. This applies to one of one resident (R95) reviewed for weight loss in the sample of 23. These failures resulted in R95 experiencing a 15% weight loss.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide clothing protectors to 2 residents (R26,R12) during meal times, and failed to provide privacy during personal cares for 1 resident (R92). These failures apply to 3 of 3 residents reviewed for dignity in the sample of 23.
Inspectors wroteBased on observation, interview, and record review, the facility failed to identify a change in condition for 1 resident (R35), failed to assess a resident with a change in condition for 1 resident (R35), failed to report a change in condition to a resident's physician for 1 resident (R35), failed to perform wound care in a manner to prevent cross contamination for 1 resident (R7), failed to obtain weights as ordered by a physician for a resident with congestive heart failure for 1 resident (R56). These failures apply to 3 of 4 residents reviewed for care and services in the sample of 23.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure ulcer interventions were in place for a resident with heel wounds (R92), failed to prevent a pressure ulcer (R95), and failed to ensure accurate wound assessments were completed (R95, R3) for 3 of 7 residents reviewed for pressure ulcers in the sample of 23.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative services to a resident (R49). This failure applies to 1 of 1 residents reviewed for range of motion in the sample of 23.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to a resident with dysphagia during meal times, and failed to provide a mechanical soft diet to a resident with dysphagia. These failures apply to 1 of 1 residents (R1) reviewed for safety and supervision in the sample of 23.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure liquid nutrition was administered as ordered, and failed to obtain weekly weights for 1 of 1 resident (R74) reviewed for feeding tubes in the sample of 23.
Inspectors wroteBased on observation, interview, and record review, the facility failed to have orders for dialysis on a resident's physician's order report for one of two residents (R50) reviewed for dialysis in the sample of 23.
32 fire safety citations on file: 8 on June 5, 2025, 13 on August 7, 2024, 11 on July 13, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| November 25, 2025 | Fine | $38,786 |
| June 5, 2025 | Fine | $44,372 |
| June 5, 2025 | Payment Denial | 12 days from June 28, 2025 |
| August 7, 2024 | Fine | $13,309 |
| February 21, 2024 | Fine | $14,050 |
| November 15, 2023 | Fine | $13,039 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Illinois | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.42 | 3.45 | 3.86 |
| Registered nurses | 0.85 | 0.72 | 0.69 |
| All nursing staff on weekends | 2.94 | 3.07 | 3.42 |
| Nurse aides | 1.78 | ||
| Licensed practical nurses | 0.79 | ||
| Nursing staff turnover (share who left in a year) | 62.2% | 44.5% | 45.8% |
| Registered nurse turnover | 59.0% | 41.8% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.33 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.62 on weekdays and 2.94 on weekends, 19% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.65 in April to June 2025 to 3.42 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.42 | 0.85 | 3.62 | 2.94 | 0.0% | 0 of 90 | 125 |
| Oct to Dec 2025 | 3.35 | 0.83 | 3.60 | 2.70 | 0.0% | 0 of 92 | 127 |
| Jul to Sep 2025 | 3.73 | 1.14 | 3.85 | 3.45 | 10.8% | 0 of 92 | 117 |
| Apr to Jun 2025 | 3.65 | 1.05 | 3.80 | 3.27 | 11.8% | 0 of 91 | 128 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Illinois, Jan to Mar 2026 | 3.26 | 0.65 | 3.40 | 2.92 | 5.4% | 0.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Illinois, all employers | |||
| CNAs (nursing assistants) | $22.10 | $18.95 to $23.26 | 68,640 |
| LPNs and LVNs | $36.06 | $30.57 to $38.25 | 17,440 |
| Registered nurses | $46.15 | $38.47 to $50.94 | 138,910 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Illinois | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 16.5 | 13.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.2 | 0.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.3 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 6.0 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.4 | 2.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 27.2 | 14.3 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 8.4 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 18.3 | 21.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 29.3 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 13.8 | 13.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.9 | 2.0 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.4 | 2.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for The Citadel at Saint Anne Place's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (45.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
45.4% this home
No different from the national rate
US median of homes 51.5% · Illinois: 106 better, 85 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 186 eligible stays.
14.9% this home
Worse than the national rate
US median of homes 10.7% · Illinois: 2 better, 14 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 180 eligible stays.
6.7% this home
No different from the national rate
US median of homes 7.1% · Illinois: 3 better, 10 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 124 eligible stays.
46.9% this home
Median of homes: Illinois50.0% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 113 residents counted.
2.4% this home
Median of homes: Illinois0.3% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 167 residents counted.
2.7% this home
Median of homes: Illinois1.5% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 167 residents counted.
88.2% this home
Median of homes: Illinois100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 68 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: CITADEL AT SAINT ANNE PLACE LLC. CMS links this home to Citadel Healthcare, a group of 16 nursing homes averaging 2.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Berger Fam Tr Ua 06252014 | Direct ownership interest | Organization | 10/01/2025 | |
| Israel Family Investment Trust | Direct ownership interest | Organization | 10/01/2025 | |
| Stern Family Investment Tr | Direct ownership interest | Organization | 10/01/2025 | |
| Graf, Marcella | Direct ownership interest | Individual | 10/01/2025 | |
| Kroll, Gabriel | Direct ownership interest | Individual | 10/01/2025 | |
| Nagel, Steven | Direct ownership interest | Individual | 10/01/2025 | |
| Cibc Bank USA | 5% or greater security interest | Organization | 10/01/2025 | |
| Aaron, Jonathan | Managing control - governing body | Individual | 10/01/2025 | |
| Ripstein, Kenneth | Managing control - governing body | Individual | 10/01/2025 | |
| Aaron, Jonathan | Operational/managerial control | Individual | 10/01/2025 | |
| Graf, Marcella | Operational/managerial control | Individual | 10/01/2025 | |
| Nika, Vasil | Operational/managerial control | Individual | 10/01/2025 | |
| Ripstein, Kenneth | Operational/managerial control | Individual | 10/01/2025 | |
| Thor, Brian | Operational/managerial control | Individual | 10/01/2025 | |
| Berger Fam Tr Ua 06252014 | Adp of the SNF | Organization | 10/01/2025 | |
| Israel Family Investment Trust | Adp of the SNF | Organization | 10/01/2025 | |
| Israel Investment Tr | Adp of the SNF | Organization | 10/01/2025 | |
| Stern Family Investment Tr | Adp of the SNF | Organization | 10/01/2025 | |
| Aaron, Jonathan | Adp of the SNF | Individual | 10/01/2025 | |
| Graf, Marcella | Adp of the SNF | Individual | 10/01/2025 | |
| Kroll, Gabriel | Adp of the SNF | Individual | 10/01/2025 | |
| Nagel, Steven | Adp of the SNF | Individual | 10/01/2025 | |
| Nika, Vasil | Adp of the SNF | Individual | 10/01/2025 | |
| Ripstein, Kenneth | Adp of the SNF | Individual | 10/01/2025 | |
| Teller, Chananel | Adp of the SNF | Individual | 10/01/2025 | |
| Thor, Brian | Adp of the SNF | Individual | 10/01/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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