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Nursing HomeMedicaid Investigative

The Citadel at Saint Anne Place

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

4405 Highcrest Road, Rockford, IL 61107179 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
4.1/5

based on 151 Google reviews

5
4
3
2
1
The Citadel at Saint Anne Place Nursing Home in Rockford, IL — Street View
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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Above-median deficiencies (19 vs median 11.0)
  • High staff turnover (51%)
  • High RN turnover (55%)

Bottom 25% in IL · Meets national RN staffing standard · Above average staffing · $126,951 in fines

Source: Medicare data

What this means for your family

While the facility is frequently praised for its clean environment and effective therapy team, the recurring reports of long response times to call lights and inconsistent hygiene are serious red flags. If you are considering this facility, we strongly recommend visiting unannounced to observe staff responsiveness and asking specific questions about how they manage medication schedules and hygiene protocols for non-ambulatory residents.

Google Reviews

Google Reviews

151 reviews on Google
The Citadel at Saint Anne Place receives highly polarized feedback, with many families praising the facility's clean environment and friendly staff, while others report severe concerns regarding neglect and poor communication. Recurring criticisms focus on long response times for call lights, inconsistent hygiene and medication management, and poor food quality. Prospective families should be aware of the significant disparity between positive experiences and reports of substandard care.

Quality Themes

Tap a score for details
Food2.0Staff6.0Clean6.0ActivitiesN/AMeds2.0MemoryN/AComms3.0Value2.0

Strengths

  • Clean, well-maintained facility
  • Friendly and welcoming front-desk staff
  • Effective physical and occupational therapy services
  • Warm and caring individual staff members

Concerns

  • Excessively long response times to call lights (mentioned by 10 reviewers)
  • Inconsistent hygiene and personal care (e.g., bed sores, lack of bathing) (mentioned by 7 reviewers)
  • Poor medication management and administration (mentioned by 5 reviewers)
  • Poor food quality, lack of variety, and unappealing meals (mentioned by 6 reviewers)
  • Difficulty reaching staff or management by phone (mentioned by 4 reviewers)

Rating Trends

Tap a year to see what changed

234'13(1)'16(3)'18(2)'20(4)'22(13)'24(45)'26(7)

Distribution · 152 analyzed

5
100
4
21
3
2
2
3
1
26

How They Respond to Reviews

70%response rate

This facility actively engages with reviewer feedback.

Questions for Your Tour

  • 1I noticed that response times to call lights are a priority for many families; could you walk me through your current process for monitoring and responding to these alerts?
  • 2Given that personal hygiene and consistent care are so important to us, how do you ensure that residents receive regular assistance with bathing and skin integrity checks?
  • 3We see that you are very active in responding to feedback online; how does that culture of communication translate into how you keep families updated on their loved ones' daily health and well-being?
  • 4With your current staffing levels, what specific protocols do you have in place to ensure that medication administration is accurate and timely for every resident?
  • 5We understand that dining is a major part of the resident experience; what steps are you taking to improve the variety and quality of the meal options provided?
  • 6Could you describe the daily activity schedule and how you encourage residents to participate in social or physical engagement throughout the week?

Personalized based on this facility's data


Key Review Excerpts

My husband is currently in St Anne's. We have had long waits for someone to answer call button. Ask the CNA to tell the nurse husband needs pain meds and maybe within an hour he might get them.

Long-term resident's family · 2017☆☆☆☆

I placed my mother here for 72 hrs while I had surgery. I am a retired RN and full time caregiver for my mom w Alzheimer's. When I discharged her she was in worse condition than when she was admitted.

Memory care family member · 2024☆☆☆☆

The staff is very pleasant and helpful and the inside of building doesn’t have a bad odor to it like some I’ve been in. The only concern is how often does the room get cleaned and mopped because the floors in my mothers room is always very sticky in bathroom and around the room.

Long-term resident's family · 2024★★★★★
Source: 151 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.83hrs
OK
Registered nurses for medical care
Total Nursing
3.35hrs
82%
All nurses + aides combined
Staff Turnover
63%
Lower is better (< 30% = good)
RN Turnover
62%
Lower is better (< 30% = good)

Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
1/ 5
Better Than Avg

5

measures

Worse Than Avg

7

measures

Mixed Results

5

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility6.0%
Better than Avg
Here
6.0%
US
12.1%
IL
52.5%
Winnebago
16.2%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚶

Residents whose walking got worse

↓ Lower is better
This Facility31.2%
Worse than Avg
Here
31.2%
US
15.3%
IL
15.9%
Winnebago
18.2%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility83.1%
Worse than Avg
Here
83.1%
US
93.4%
IL
90.0%
Winnebago
96.0%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility17.4%
Better than Avg
Here
17.4%
US
19.4%
IL
21.1%
Winnebago
25.2%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility19.6%
Worse than Avg
Here
19.6%
US
14.4%
IL
14.2%
Winnebago
16.3%
🩹

Residents with pressure sores (bedsores)

↓ Lower is better
This Facility9.2%
Worse than Avg
Here
9.2%
US
4.9%
IL
5.0%
Winnebago
5.7%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility71.5%
Mixed vs Avgs
Here
71.5%
US
81.8%
IL
69.0%
Winnebago
87.6%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility72.5%
Mixed vs Avgs
Here
72.5%
US
79.7%
IL
63.1%
Winnebago
81.0%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.5%
Mixed vs Avgs
Here
1.5%
US
1.6%
IL
2.4%
Winnebago
1.4%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

18deficiencies
7penalties
Above state avg (12.0)
18 complaint-triggered
$126,951 in fines

Families have filed multiple complaints triggering inspections, with recurring deficiencies in accident prevention and safety oversight appearing across recent surveys from 2023 to 2025. The facility shows persistent problems with medication management, wound care, and maintaining safe environments free from hazards. While all deficiencies have correction dates, the pattern of repeated safety violations and complaint-driven inspections suggests ongoing care quality concerns families should investigate thoroughly.

Dec 16, 2025Complaint
1
0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nov 25, 2025Complaint
5
0684Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0550Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0694Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Jul 8, 2025Complaint
1
0684Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Jun 5, 2025Routine
18
0686Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0692Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0161Potential for harm · PatternCorrected

Construction Deficiencies

Use approved construction type or materials.

0211Potential for harm · PatternCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0223Potential for harm · PatternCorrected

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

0324Potential for harm · PatternCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0374Potential for harm · PatternCorrected

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0755Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0805Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0725Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Jun 5, 2025Complaint
1
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Apr 29, 2025Complaint
2
0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Federal Penalties

Fine

Nov 25, 2025

$59,670

Payment Denial

Jun 5, 2025

12-day denial

Fine

Jun 5, 2025

$68,265

Fine

Aug 7, 2024

$13,309

Fine

Feb 21, 2024

$14,050

Fine

Nov 15, 2023

$13,039

Fine

Jul 13, 2023

$18,288

Ownership & Operations

Who Operates This Facility

Owner / Operator

The Citadel at Saint Anne Place

Organization Type

nonprofit

Ownership & Management

Owners

Undisclosed

Ownership Data Not Available · Organization

Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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