The Citadel at Saint Anne Place: Wound Care Failure - IL
The resident, identified in inspection records only as Resident 5, had developed moisture-associated skin damage on his buttocks. The condition, known as MASD, occurs when prolonged exposure to moisture breaks down the outer layers of skin, leaving tissue raw and susceptible to further injury. It is not a pressure wound, but it shares the same risk landscape: immobility, poor circulation, extended time in one position.
A staff member identified in the report as V17 told inspectors that when he found the MASD on Resident 5's buttocks, he debrided it. His word for what he did was more direct than that clinical term. He said he scraped it off.
Debridement, when performed correctly, is a medical procedure for removing dead or damaged tissue to allow healing. It is done with instruments, or through chemical agents, or through other controlled methods. It is not done by hand, and it is not something a nursing home worker does on his own when he notices a wound during care.
Resident 5's own records made the stakes plain. A Braden Scale assessment completed on November 5, 2025, three weeks before the inspection, rated him as high risk for pressure sore development. The Braden Scale measures factors including how much a person can move independently, how well their skin tolerates moisture, and whether their circulation and nutrition are adequate to support tissue health. A high-risk score means the skin is already compromised. It means small failures in care compound quickly.
The facility's own wound prevention policy, in place since January 2017, acknowledges the basic mechanism: pressure injuries form when a resident stays in the same position for too long, reducing blood flow and destroying tissue. The policy existed. Whether the staff member who scraped Resident 5's wound had been trained on it, or understood what it meant for how he should respond when he found damaged skin, the inspection report does not say.
CMS classified the violation under F0686, which covers pressure ulcer prevention and skin integrity. Inspectors rated the level of harm as minimal harm or potential for actual harm, the lower end of the harm scale. The deficiency affected few residents.
Those classifications matter for regulatory purposes. They determine fines, follow-up requirements, and how the violation appears in the facility's public record. What they do not capture is what it means to be a high-risk resident in a nursing home, dependent on staff to recognize when something is wrong and to respond in a way that makes things better rather than worse.
Resident 5's skin was already breaking down when V17 found the wound. The inspection record does not describe what the wound looked like after V17 scraped it. It does not say whether a nurse was called, whether a physician was notified, or whether the wound was documented and monitored in the days that followed. The report surfaces one moment, one action, one staff member's account of what he did, and stops there.
The Citadel at Saint Anne Place is located at 4405 Highcrest Road in Rockford. The complaint inspection was completed November 25, 2025. The facility's plan of correction was not included in the inspection materials reviewed.
What the record shows is a man rated high-risk, with damaged skin on his buttocks, and a worker who responded by scraping the wound with his hands.
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.
The resident, identified in inspection records only as Resident 5, had developed moisture-associated skin damage on his buttocks.
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.