Map showing the location of The Citadel at Saint Anne Place in ROCKFORD, Illinois
4405 HIGHCREST ROAD, ROCKFORD, IL, 61107

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • IllinoisLowest tier among peers665 rated homes · average 2.5★
  • Winnebago CountyLowest tier among peers15 rated homes · average 2.6★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.7 vs IL avg
  • StaffingCan add or remove a star4★+1.9 vs IL avg
  • Quality measuresCan add or remove a star1★−1.9 vs IL avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersIL avg2.7★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 82% of peersIL avg2.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments1★Lowest tier among peersIL avg2.9★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.73hrsAbove 71% of peersIL avg3.49Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only1.14hrsAbove 88% of peersIL avg0.73Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better51%Above only 35% of peersIL avg46%RN turnover55%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$126,951Above only 28% of peersIL avg$95,677Fines · denials5 · 1
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
42citations
13inspection dates
10actual harm (G–I)
0immediate jeopardy (J–L)
Dec 16, 2025most recent

Citations by monthFeb 2023 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 16, 20251 citationCycle 1worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Dec 18, 2025
Nov 25, 20255 citationsCycle 1worst G · actual harm
  1. F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareD · isolatedCorrected Dec 5, 2025
  2. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Nov 26, 2025
  3. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Dec 5, 2025
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Dec 5, 2025
  5. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Dec 5, 2025
Jul 8, 20251 citationCycle 1worst G · actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Jul 10, 2025
Jun 5, 202511 citationsCycle 1worst G · actual harm$68,265, payment denial
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jun 19, 2025
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jun 20, 2025
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jun 17, 2025
  4. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jul 2, 2025
  5. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jun 17, 2025
  6. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Jul 3, 2025
  7. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Jun 17, 2025
  8. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jun 17, 2025
  9. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesD · isolatedCorrected Jun 17, 2025
  10. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Jun 17, 2025
  11. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryE · patternCorrected Jul 1, 2025
Apr 29, 20251 citationCycle 1worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 30, 2025
Aug 7, 20247 citationsCycle 2worst G · actual harm$13,309
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Aug 14, 2024
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 14, 2024
  3. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Aug 14, 2024
  4. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Aug 14, 2024
  5. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Aug 8, 2024
  6. F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceD · isolatedCorrected Aug 8, 2024
  7. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Aug 14, 2024
Jul 17, 20241 citationCycle 2worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jul 22, 2024
Apr 3, 20241 citationCycle 2worst D · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Apr 10, 2024
Mar 13, 20242 citationsCycle 2worst D · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Mar 21, 2024
  2. F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Mar 21, 2024
Feb 21, 20241 citationCycle 2worst G · actual harm$14,050
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Feb 22, 2024
Nov 15, 20232 citationsCycle 3worst G · actual harm$13,039
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Nov 17, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Nov 16, 2023
Jul 13, 20238 citationsCycle 3worst G · actual harm$18,288
  1. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jul 28, 2023
  2. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jul 28, 2023
  3. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jul 28, 2023
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 28, 2023
  5. F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Quality of Life and CareD · isolatedCorrected Jul 28, 2023
  6. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Jul 28, 2023
  7. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jul 28, 2023
  8. F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareD · isolatedCorrected Jul 28, 2023
Feb 21, 20231 citationCycle 3worst G · actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Feb 27, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.73hrsAbove 71% of peers+0.24 vs IL avg
  • Registered nursesRN hours only1.14hrsAbove 88% of peers+0.41 vs IL avg
  • Licensed practical nursesLPN hours0.72hrs
  • Nurse aidesCNA hours1.88hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.45hrs
  • Illinois average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better51%Above only 35% of peersIL avg 46%
  • RN turnoverRegistered nurses only55%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy179 certified beds · ~117 residents a day66%Above only 28% of peersIL avg 74%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $126,951In fines
  • 5Fines
  • 1Payment denial
  • $95,677IL avg in fines
Above only 28% of peersFewer fines than 28% of rated homes in Illinois

Actions on record

  1. Jun 5, 2025Civil money penalty$68,265
  2. Jun 5, 2025Denial of payment for new admissionsfrom Jun 28, 2025
  3. Aug 7, 2024Civil money penalty$13,309
  4. Feb 21, 2024Civil money penalty$14,050
  5. Nov 15, 2023Civil money penalty$13,039
  6. Jul 13, 2023Civil money penalty$18,288

Ownership

As filed with CMS

Structure

Ownership type
Non profit - Church related
Chain
Independent
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Presence Care Transformation Corporation
Indirect owners (5%+)
  • Presence Health Network
Operational or managerial control
  • Ascension Health Senior Care
  • Presence Care Transformation Corporation
Corporate directors
  • Robin Binek
  • Ryan Breedlove
  • Kellie Gronefeld
  • Lisa Musgrave
  • Kenneth Smoot
Corporate officers
  • Erin Shadbolt
Contracted managers
  • Vasil Nika

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 145563 · 4405 HIGHCREST ROAD, ROCKFORD, IL, 61107.
  • Percentiles compare this facility with every rated nursing home in Illinois and Winnebago County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

Own or manage a facility?

Claim your free listing to correct details, reply to reviews, and show your verified badge.

Claim your facility

Read our latest articles