Map showing the location of The Citadel at Saint Joseph Village in FREEPORT, Illinois
659 EAST JEFFERSON STREET, FREEPORT, IL, 61032

Overall Score

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

Where it ranks

  • IllinoisAbove only 37% of peers665 rated homes · average 2.5★
  • Stephenson CountyAbove only 25% of peers5 rated homes · average 2.2★
  • United StatesAbove only 20% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.7 vs IL avg
  • StaffingCan add or remove a star1★−1.1 vs IL avg
  • Quality measuresCan add or remove a star5★+2.1 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 cycles2★Above only 19% of 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 turnover1★Lowest tier among 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 assessments5★Above 88% of 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 staffhrsNo dataIL 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 onlyhrsNo dataIL 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 better55%Above only 26% of peersIL avg46%RN turnover59%
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$110,367Above only 32% 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
49citations
21inspection dates
7actual harm (G–I)
0immediate jeopardy (J–L)
Dec 6, 2025most recent

Citations by monthMar 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 6, 20251 citationCycle 1worst E · no actual harm
  1. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryE · patternCorrected Dec 12, 2025
Sep 2, 20251 citationCycle 1worst 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 Sep 8, 2025
Jul 21, 20253 citationsCycle 1worst D · no actual harm
  1. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jul 29, 2025
  2. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jul 29, 2025
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 29, 2025
Jun 13, 20251 citationCycle 1worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 3, 2025
Jun 10, 20251 citationCycle 1worst 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 Jul 3, 2025
May 28, 20254 citationsCycle 1worst E · no actual harm
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jul 3, 2025
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Jul 3, 2025
  3. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jul 3, 2025
  4. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 3, 2025
Mar 18, 20251 citationCycle 1worst G · actual harm$14,505
  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 Mar 8, 2025
Dec 11, 20247 citationsCycle 1worst G · actual harm$14,788
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Dec 18, 2024
  2. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Dec 18, 2024
  3. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Dec 18, 2024
  4. 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, 2024
  5. F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareG · isolatedCorrected Dec 18, 2024
  6. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Dec 18, 2024
  7. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryE · patternCorrected Dec 18, 2024
Sep 13, 20242 citationsCycle 2worst G · actual harm$12,581
  1. F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareD · isolatedCorrected Sep 24, 2024
  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 Sep 24, 2024
Aug 1, 20242 citationsCycle 2worst G · actual harm$12,248
  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 Aug 9, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Aug 9, 2024
May 21, 20241 citationCycle 2worst D · no actual harm
  1. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Jun 4, 2024
Apr 23, 20241 citationCycle 2worst D · no actual harm
  1. F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected May 1, 2024
Feb 8, 20248 citationsCycle 2worst G · actual harm$56,245, payment denial
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Mar 4, 2024
  2. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Mar 13, 2024
  3. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 4, 2024
  4. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Mar 4, 2024
  5. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Mar 4, 2024
  6. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Mar 4, 2024
  7. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 4, 2024
  8. F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningD · isolatedCorrected Mar 4, 2024
Nov 9, 20231 citationCycle 3worst D · no actual harm
  1. F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlD · isolatedCorrected Nov 23, 2023
Nov 1, 20231 citationCycle 3worst D · no actual harm
  1. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 20, 2023
Oct 10, 20231 citationCycle 3worst D · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Oct 27, 2023
Jul 6, 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 Jul 31, 2023
May 10, 20231 citationCycle 3worst E · no actual harm
  1. F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Jun 6, 2023
Mar 29, 20238 citationsCycle 3worst F · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 22, 2023
  2. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Apr 22, 2023
  3. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Apr 22, 2023
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Apr 22, 2023
  5. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Apr 22, 2023
  6. 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 22, 2023
  7. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Apr 22, 2023
  8. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Apr 22, 2023
Mar 22, 20232 citationsCycle 3worst 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 Apr 10, 2023
  2. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Apr 10, 2023
Mar 9, 20231 citationCycle 3worst 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 5, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combinedhrs
  • Registered nursesRN hours onlyhrs
  • Licensed practical nursesLPN hourshrs
  • Nurse aidesCNA hourshrs
  • Weekend nursingAll staff on Saturdays and Sundayshrs
  • Illinois average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better55%Above only 26% of peersIL avg 46%
  • RN turnoverRegistered nurses only59%Not ranked by CMS
  • Administrators who leftIn the past year
  • Occupancy124 certified beds · ~78 residents a day63%Above only 24% of peersIL avg 74%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $110,367In fines
  • 5Fines
  • 1Payment denial
  • $95,677IL avg in fines
Above only 32% of peersFewer fines than 32% of rated homes in Illinois

Actions on record

  1. Mar 18, 2025Civil money penalty$14,505
  2. Dec 11, 2024Civil money penalty$14,788
  3. Sep 13, 2024Civil money penalty$12,581
  4. Aug 1, 2024Civil money penalty$12,248
  5. Feb 8, 2024Civil money penalty$56,245
  6. Feb 8, 2024Denial of payment for new admissionsfrom Mar 9, 2024

Ownership

As filed with CMS

Structure

Ownership type
Non profit - Corporation
Chain
Ascension Living20 facilities in the chain2.6★ chain average
Certification
Medicare and Medicaid
Location type
Rural
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Ascension Health Senior Care
Operational or managerial control
  • Ascension Health Senior Care
Corporate directors
  • Robin Binek
  • Ryan Breedlove
  • Kellie Gronefeld
  • Lisa Musgrave
  • Erin Shadbolt
  • Kenneth Smoot
Corporate officers
  • Erin Shadbolt
Contracted managers
  • Demetrios Petrovas
Managing employees
  • Georgette Parent

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 145935 · 659 EAST JEFFERSON STREET, FREEPORT, IL, 61032.
  • Percentiles compare this facility with every rated nursing home in Illinois and Stephenson 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.

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