Citadel at Saint Anne Place: Missed Medications - IL
A resident at The Citadel at Saint Anne Place went eleven hours without her seizure medication on September 20, 2025, according to a federal inspection report. By the time someone finally gave it to her, Bingo was over and the afternoon was gone.
"It took 11 hours for me to finally get my Depakote," the resident told inspectors during a November 21 interview. "It was on September 20th. I talked to the night shift and then the day shift and then the swing shift and no one had time to give me my medication. Finally, it was given to me after Bingo — after 2 PM. I should get it twice a day at 8 AM and 8 PM."
Depakote is an anticonvulsant. Missing a dose carries real consequences for someone prescribed the drug to control seizures.
That was not the only medication she went without that day. When inspectors pulled her Medication Administration Record for September, the form showed no nurse's initials for the 8 AM Depakote dose and no initials for the 8 PM dose either. The same record showed her 300-milligram dose of Bupropion XL, an antidepressant, was also not documented as given at 8 AM. Her 2-milligram dose of Abilify, an antipsychotic, showed no initials for 8 PM. Three medications. Two scheduled times. No documentation that any of them were administered as ordered.
The ombudsman assigned to the facility had already heard about it.
"I know she was really upset when she went the whole day without getting her medications," the ombudsman told inspectors that same afternoon.
The Director of Nursing confirmed that an agency nurse, meaning a contracted worker brought in from outside the facility's regular staff, had been assigned to administer this resident's medications on September 20. When an inspector called that nurse directly on November 21, they left a message and requested a callback. The nurse never called back. The survey team exited the facility on November 25 without ever hearing from her.
The inspection, triggered by a complaint, covered a sample of 13 residents. Inspectors reviewed medication administration for 3 of them. The failures applied to 1.
That ratio can read as reassuring. One resident, one bad day, one agency nurse who didn't answer the phone. But the resident had done everything right. She had asked. She had asked again. She had tracked down workers across three separate shifts and told each of them she needed her medications. The system's answer, across an entire day, was that no one had time.
Federal inspectors classified the violation at a level of minimal harm or potential for actual harm. The finding was cited under the requirement that facilities provide pharmaceutical services to meet the needs of each resident.
The Citadel at Saint Anne Place is a nursing facility in Rockford, Illinois. The inspection was completed November 25, 2025.
What the record does not show is anyone at the facility catching this on September 20 before the resident spent her day waiting. It does not show a supervisor who noticed the morning doses were never pulled. It does not show a charge nurse who followed up when the agency worker's shift ended. It shows a medication administration record with blank spaces where initials should have been, and a resident who remembers exactly what day it was and exactly how long she waited.
She still knew the number. Eleven hours.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Citadel At Saint Anne Place from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 23, 2026 · Our methodology
The Citadel at Saint Anne Place in ROCKFORD, IL was cited for violations during a health inspection on November 25, 2025.
A resident at The Citadel at Saint Anne Place went eleven hours without her seizure medication on September 20, 2025, according to a federal inspection report.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.