The Citadel At Saint Anne Place

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Based on interview and record review the facility failed to ensure residents were treated with dignity by answering call lights in a timely manner. This applies to 4 of 4 residents (Resident R15, Resident R16, Resident R17, Resident R18) reviewed for dignity in the sample of 18. The findings include: On 11/25/25 at 11:30 AM Resident R15 stated, It takes a long time, but I do not know how long because I do not have a clock. It feels like at least 20 - 30 minutes most of the time. It is worse during shift change or when they are on their breaks. I lay in wet diapers quite a while- all

the time. They often come in and turn the light off and say they will be back and sometimes they come back and sometimes they don't. It is not good. Some are very nice and others are not. Some do not want to listen to what I want them to do. One girl yesterday threatened to leave the room and not come back.On 11/25/25 at 11:40AM Resident R16 stated, Sometimes an hour- usually a little less. Sometimes I wet my pants because I have to wait so long. Makes me feel helpless. Nighttime I think is the worst. Some of the staff are nice, some are very rude. They are really good at turning off the call lights. I tell them as many times as they turn them off; I will turn it back on.On 11/25/25 at 11:45AM Resident R17 stated, I have waited anywhere from 15 minutes to 2 hours to have my call light answered. This IV has been beeping for 30 minutes now. The nurse said she was going to set a timer on her watch so she could come and turn it off. (continued to beep until Surveyor reported to nurse at 12:15PM). I have a catheter and a stoma, so I have that going for me but when I put my call light on, I usually need a pain pill, or I need to be repositioned in the bed. When they don't come it makes me feel like I have no value, like my concerns and my needs are immaterial. They said that whenever a CNA (Certified Nurse Assistant) walks past the room and my call light is on, they should be checking to see what I need. That never happens. My doctor is currently looking for another place for me to live.On 11/25/25 at 12:00PM Resident R18 stated, Sometimes the call light doesn't get answered at all and I try to make it to the bathroom on my own. It is either that or wet the bed. Plenty of time I have dribbled in my Depends because I can't get there in time. What does that sign say? (Sign on the bathroom door reads- Wait for the nurse, don't get up alone. Well sometimes that is not possible. I always tell them they are going to have a bigger mess to clean up if they don't come in time. I have fallen a couple of times, and I am afraid it will happen again. But I have to go to the bathroom. If they just take me in there then I will find my way back. Sometimes that light in there (bathroom) is still going off 15-20 minutes after I have gotten myself back in the bed.The facility Residents' Rights for People in Long-term Care Facilities Pamphlet given to residents on admission to the facility stated, Your facility must provide services to keep your physical and mental health, and sense of satisfaction.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Citadel at Saint Anne Place

4405 Highcrest Road Rockford, IL 61107

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm

immediately shared with the resident and/or the resident representative.and are reported to and consulted with the attending physician.an accident involving the resident, which results in injury and has the potential for requiring physician intervention.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Citadel at Saint Anne Place

4405 Highcrest Road Rockford, IL 61107

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm

and (Resident R5) had MASD on his buttocks and he debrided it. (V17) said he scraped it off. Resident R5's Braden Scale for Predicting Pressure Sore Risk dated 11/5/25 shows that Resident R5 was High Risk. The facility policy entitled Prevention of Pressure Wounds dated January 2017 states, Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Citadel at Saint Anne Place

4405 Highcrest Road Rockford, IL 61107

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694

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

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview and record review the facility failed to ensure sterile catheter dressing changes were performed for a resident with a PICC (Peripherally Inserted Central Catheter) this applies to 1 of 3 residents (Resident R2) reviewed for central lines in the sample of 18. The findings include: On 11/21/25 at 8:28 AM, Resident R2 was in her room lying in bed. Resident R2 said she had a PICC in her left upper arm placed on 9/16/25, because she had infection in her knee, and she was getting IV antibiotics. The staff were not changing the dressing weekly. She told the staff it needed to be changed weekly, and they said they did not know how to do change the dressing because they were not RN's (Registered Nurse's). Resident R2 said her PICC line was removed because it got clogged.On 11/21/25 at 9:40 AM, V11 (RN) said PICC line dressings should be changed once a week. Only RN's can change the dressing on PICC lines and there should be an order when to change the dressing. On 11/21/25 at 3:05 PM, V2 (Director of Nursing-DON) said Resident R2 had a PICC line for IV antibiotics. V2 said residents with PICC lines should have weekly dressing changes. V2 said nursing should put in the order to change the PICC lines to ensure the dressing is done. V2 confirmed Resident R2 did not have orders entered to change her PICC line dressing weekly and Resident R2's dressings were not done. Resident R2's Vascular Access Order/Consent is dated 9/16/25 for insertion of her PICC line. Resident R2's Physician Order Sheets dated October 2025 shows there is no order to change her PICC line dressing. Resident R2's Medication Administration Record (M.A.R.) shows on 10/21/25 orders to discontinue PICC line and IV antibiotics for treatment of a wound infection. The facility's Central Venous Catheter Dressing Changes Policy revised 2016 states, Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections.dressings must stay clean, dry and intact.change transparent semi-permeable membrane dressings at least every 5-7 days and PRN (as needed when wet, soiled or not intact). equipment and supplies to replace sterile dressing.sterile central venous catheter dressing kit. The following information should be recorded in the residents medical record: date and time the dressing was changed, location and objective of insertion site .signature and title of the person recording the data.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Citadel at Saint Anne Place

4405 Highcrest Road Rockford, IL 61107

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

Based on interview and record review the facility failed to administer medications as ordered by the resident's physician. This applies to 1 of 3 residents (Resident R1) reviewed for medication administration in the sample of 13.The findings include: On 11/21/25 at 9:45 AM Resident R1 stated, It took 11 hours for me to finally get my Depakote. 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 2PM). I should get it twice a day at 8AMand 8PM.On 11/21/25 at 3:15 PM V8 (Ombudsman) stated, I know she was really upset when she went the whole day without getting her medications.On 11/21/25 Resident R1's Medication Administration Record for September was reviewed and shows no initials for the administration of Depakote (Anticonvulsant) 125 milligram (mg) at 8:00 AM or 8:00 PM on September 20, 2025. This same form also shows no initials for the administration of Resident R1's Bupropion XL (Antidepressant) 300mg at 8:00 AM or her Abilify (Antipsychotic) 2mg at 8:00 PM. On 11/21/25 V2 (Director of Nursing) confirmed that V7 (Agency Nurse) was the nurse assigned to administer Resident R1's medications on September 20, 2025. On 11/21/25 Surveyor called V7 and left a message with a request to return the call. No return call was received prior to survey exit on 11/25/25.

Event ID:

Facility ID:

If continuation sheet