The Citadel At Saint Anne Place
The Citadel at Saint Anne Place in ROCKFORD, IL — inspection on November 25, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 (R15, R16, R17, R18) reviewed for dignity in the sample of 18.
The findings include: On 11/25/25 at 11:30 AM 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 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 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 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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Citadel at Saint Anne Place
4405 Highcrest Road Rockford, IL 61107
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Citadel at Saint Anne Place
4405 Highcrest Road Rockford, IL 61107
SUMMARY STATEMENT OF DEFICIENCIES
and (R5) had MASD on his buttocks and he debrided it. (V17) said he scraped it off. R5's Braden Scale for Predicting Pressure Sore Risk dated 11/5/25 shows that 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Citadel at Saint Anne Place
4405 Highcrest Road Rockford, IL 61107
SUMMARY STATEMENT OF DEFICIENCIES
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 (R2) reviewed for central lines in the sample of 18.
The findings include: On 11/21/25 at 8:28 AM, R2 was in her room lying in bed. 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). 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 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 R2 did not have orders entered to change her PICC line dressing weekly and R2's dressings were not done.
R2's Vascular Access Order/Consent is dated 9/16/25 for insertion of her PICC line. R2's Physician Order Sheets dated October 2025 shows there is no order to change her PICC line dressing. 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Citadel at Saint Anne Place
4405 Highcrest Road Rockford, IL 61107
SUMMARY STATEMENT OF DEFICIENCIES
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 (R1) reviewed for medication administration in the sample of 13.The findings include: On 11/21/25 at 9:45 AM 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 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 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 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.
Facility ID: