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Home / Illinois / Rockford

Pa Peterson at the Citadel

1311 Parkview Avenue, Rockford, IL 61107 · Winnebago County · (815) 399-8832

129 certified beds, about 120 residents a day · For profit - Partnership · Medicare and Medicaid since 1993

CMS abuse icon: cited for abuse in a recent inspection Part of a continuing care retirement community Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
2 of 5
Staffing
1 of 5
Quality measures
4 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 145751 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on May 21, 2025, inspectors cited 12 health deficiencies (the Illinois average is 12.6, the national average 9.2).

Of 65 health citations since June 2023, 3 were rated as actual harm or immediate jeopardy to residents.

CMS lists 1 fine totaling $21,212 in the last three years; the largest was $21,212, and the latest is dated July 10, 2024.

Nurses and nurse aides worked 3.70 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 0.62 of those hours.

59.6% of nursing staff left within the year CMS measured (Illinois average 44.5%).

CMS links it to Citadel Healthcare, an affiliated group of 16 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 65 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
3G
0H
0I
Potential for more than minimal harm
51D
8E
3F
Potential for minimal harm
0A
0B
0C
July 7, 2026Complaint inspection · 1 citation
  1. D
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 10, 2026
    Inspectors wroteBased on interview and record review the facility failed to protect a resident from misappropriation of funds. This applies to one of three residents (R1) reviewed for misappropriation in the sample of six.
June 25, 2026Complaint inspection · 2 citations
  1. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 2, 2026
    Inspectors wroteBased on interview and record review, the facility failed to ensure the facility was free from physical abuse for 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 10The
  2. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 2, 2026
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure relieving interventions of air mattress pumps were on and set to the residents' weights. This applies to 3 of 6 residents (R6, R7 and R9) reviewed for pressure injuries in the sample of 10.
April 3, 2026Complaint inspection · 1 citation
  1. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 8, 2026
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was transferred using a mechanical lift in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 7.
March 2, 2026Complaint inspection · 1 citation
  1. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 5, 2026
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure pressure ulcer prevention interventions were in place for residents at risk for pressure ulcers and failed to ensure treatment orders were implemented for a resident with a pressure ulcer for 3 of 3 residents (R1, R2 and R3) reviewed for pressure ulcers in the sample of 3.
December 2, 2025Complaint inspection · 1 citation
  1. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 5, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure a medication was available for administration for 1 of 3 residents (R1) reviewed for medications in the sample of 4.
November 24, 2025Complaint inspection · 1 citation
  1. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 4, 2025
    Inspectors wroteBased on interview and record review the facility failed to ensure a resident was safely transferred with a gait belt and failed to ensure a resident was safely moved outside in a wheelchair. This applies to 2 of 3 residents (R1 and R2) reviewed for safety in the sample of 3.
May 21, 2025Standard inspection, Complaint inspection · 13 citations
  1. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 30, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to have orders in place for non-pressure wounds, failed to have interventions in place for non-pressure wound healing, and failed to ensure a resident received a specialist consult for vaginal pain for three of 24 residents (R93, R362, R365) reviewed for quality of care in the sample of 24.
  2. E
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 30, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an adequate amount of staff were scheduled to meet the needs of residents. This failure has the potential to affect all 36 residents residing on the third floor of the facility.
  3. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 30, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to don personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) and failed to change gloves and perform hand hygiene in a manner to prevent cross contamination for five of 24 residents (R66, R93, R34 R16, R362) reviewed for infection control in the sample of 24.
  4. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 30, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was treated with dignity and respect for 1 of 24 residents (R88) reviewed for resident's rights in the sample of 24.
  5. D
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    F605 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 30, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure as needed anti-anxiety medications had a stop date for two of five residents (R66, R104) reviewed for chemical restraints in the sample of 24.
  6. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 30, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure activities of daily living (ADL) assistance was provided for dependent residents for three of 24 residents (R16, R34, R93) reviewed for incontinence care in the sample of 24.
  7. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 30, 2025
    Inspectors wroteBased on interview and record review, the facility failed to assess and implement treatment interventions for pressure wounds, and failed to ensure pressure relieving interventions were in place for 3 of 8 residents (R77, R365, R362), reviewed for pressure wounds in the sample of 24.
  8. D
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 30, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure splints were in place for residents with contractures for 2 of 5 residents (R30, R12) reviewed for limited range of motion in the sample of 24.
  9. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 30, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was transferred safely for 1 (R66) of 24 residents reviewed for safety/supervision in the sample of 24.
  10. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 30, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure R44's steel oxygen cylinders were stored to prevent damage to the cylinders for 1 of 5 residents (R44) reviewed for respiratory services in the sample of 24.
  11. D
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 30, 2025
    Inspectors wroteBased observation, interview and record review the facility failed to ensure medications were legibly labeled and dated when opened for 2 of 2 residents (R24 R18) reviewed for medication storage in the sample of 24.
  12. D
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 30, 2025
    Inspectors wroteBased on interview and record review the facility failed to offer a resident the pneumonia vaccination which applies to 1 of 5 residents (R36) reviewed for vaccinations in a sample of 24
  13. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 30, 2025
    Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation and failed to obtain and/or maintain documentation of a thorough investigation of monetary misappropriation for 1 of 24 residents (R364) in the sample of 24 reviewed for abuse.
December 13, 2024Complaint inspection · 1 citation
  1. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 19, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with oral and/or denture care for one (R7) of three residents reviewed for activities of daily living (ADL); and the facility failed to follow its policy and procedures by not ensuring that a resident with a self-care deficit (R7) received the necessary assistance to maintain oral hygiene.
December 10, 2024Complaint inspection · 1 citation
  1. D
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 17, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a homelike environment by having wallpaper falling down that had a black substance on it for 2 of 4 residents (R1 and R6) reviewed for homelike environment in the sample of 4.
November 19, 2024Complaint inspection · 5 citations
  1. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) November 29, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure controlled medications were documented as administered in the narcotic reconciliation binder for 8 of 9 residents (R4, R6-R12) reviewed for controlled medications in the sample of 13.
  2. D
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 29, 2024
    Inspectors wroteBased on interview and record review, the facility failed to ensure misappropriation of medications did not occur for 1 of 3 residents (R2) reviewed for misappropriation of medications in the sample of 13.
  3. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 29, 2024
    Inspectors wroteBased on interview and record review, the facility failed to report an allegation of misappropriation of medications to the Illinois Department of Public Health for 1 of 3 residents (R2) reviewed for misappropriation of medications in the sample of 13.
  4. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 29, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to conduct a thorough investigation of an allegation of misappropriation of medication for 1 of 3 residents (R2) reviewed for misappropriation of medications in the sample of 13.
  5. D
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 29, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure controlled medications were stored under a double lock in the medication room for 2 of 9 residents (R6 and R13) reviewed for controlled medications in the sample of 13.
October 18, 2024Complaint inspection · 2 citations
  1. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 29, 2024
    Inspectors wroteBased on interview and record review the facility failed to ensure that staff follow the Abuse Prevention Policy. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 3.
  2. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 29, 2024
    Inspectors wroteBased on interview and record review the facility failed to ensure that staff report suspicions of sexual abuse to administration in a timely manner. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 3.
October 16, 2024Complaint inspection · 1 citation
  1. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 29, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to notify a resident's Power of Attorney regarding a reported fall, new onset of right ankle swelling, and an Xray order. This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 4.
October 7, 2024Complaint inspection · 2 citations
  1. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 29, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who had a change of condition received services timely for suspected urinary tract infection. This applies to 1 of 4 residents (R1) reviewed for quality of care in the sample of 4.
  2. D
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 29, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with significant weight loss received the recommended nutritional supplements. This applies to 1 of 4 residents (R1) reviewed for weight loss in the sample of 4.
September 24, 2024Complaint inspection · 1 citation
  1. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 7, 2024
    Inspectors wroteBased on interview and record review the facility failed to ensure an intravenous antibiotic was administered and failed to administer medication at the scheduled times for 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 10.
September 12, 2024Complaint inspection · 3 citations
  1. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 18, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure daily dressing changes were completed as ordered, and failed to ensure as needed dressing changes were completed when a dressing was loose for 2 of 3 residents (R3 & R4) reviewed for dressings in the sample of 8.
  2. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 18, 2024
    Inspectors wroteBased on interview and record review the facility failed to give a resident an as needed nebulizer treatment when he was wheezing for 1 of 3 residents (R1) reviewed for medications and respiratory treatments in the sample of 8.
  3. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 18, 2024
    Inspectors wroteBased on interview and record review the facility failed to give a resident his evening medications for 1 of 3 residents (R1) reviewed for medications and respiratory treatments in the sample of 8.
August 30, 2024Complaint inspection · 1 citation
  1. D
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    F744 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 10, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with a diagnosis of dementia had individualized interventions with behaviors of agitation/restlessness while in bed. This applies to 1 of 3 residents (R1) reviewed for dementia care in the sample of 3.
August 20, 2024Complaint inspection · 1 citation
  1. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 4, 2024
    Inspectors wroteBased on interview and record review the facility failed to clarify conflicting admitting orders for a resident who was re-admitted to the facility after hospitalization to ensure necessary care and services were provided. This applies to 1 of 3 (R1) reviewed for quality of care in the sample of 4.
July 18, 2024Complaint inspection · 1 citation
  1. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) July 29, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 4 of 4 residents (R1, R2, R3, and R4) reviewed for infection control in the sample of 4.
July 10, 2024Standard inspection · 13 citations
  1. G
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) July 25, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to assess and monitor a resident's(R94) ankle. This failure resulted in R94 developing an infected ankle that caused a post-surgical screw to protrude out of her ankle and be admitted to the local hospital for surgical cleaning and repair. The facility failed to identify, assess and implement treatment interventions for a resident(R24) with new wounds. This applies to 2 of 25 residents (R24 and R94) reviewed for quality of care in the sample of 25.
  2. G
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) July 25, 2024
    Inspectors wroteBased on observation, interview, and record review the facility to report new pressure injuries. The facility failed to ensure pressure injury prevention interventions were in place. The facility failed to identify a resident's pressure injury prior to the injury becoming a Stage III injury. These failures resulted in R101 developing a Stage III pressure injury to her coccyx and Stage II pressure injuries to each of her buttocks. The facility failed to ensure pressure treatment interventions were in place and failed to complete weekly assessments on residents(R82, R24) with pressure injuries. This applies to 3 of 11 residents (R101, R82, R24) reviewed for pressure injuries in the sample of 25.
  3. G
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) July 25, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident (R121) was assessed, in-person, by a Certified Dietary Manager or Registered Dietician, upon admission to the facility. The facility failed to obtain and monitor a resident's (R121) weight as per physician order. These failures resulted in R121 sustaining a significant weight loss of 20.3 % (49.4 pounds) in 25 days. This applies to 1 of 10 residents (R121) reviewed for weight loss in the sample of 25.
  4. F
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    F803 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) July 25, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to follow the chili recipe for the noon meal. This applies to all 127 residents.
  5. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) July 25, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to provide ADL (activities of daily living) assistance to residents that required staff assistance for toileting and incontinence care for 7 of 25 residents (R101, R121, R113, R103, R9, R78, R24) reviewed for activities of daily living in the sample of 25.
  6. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) July 29, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff removed their gloves and washed their hands to prevent cross contamination, failed to don personal protective equipment before entering an isolation room, and failed to implement Enhanced Barrier Precautions (EBP) for 6 of 25 residents (R9, R24, R58, R82, R101 and R103) reviewed for infection control in the sample of 25.
  7. E
    Educate 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.
    F887 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) July 25, 2024
    Inspectors wroteBased on interview and record review the facility failed to ensure a resident was provided the COVID-19 vaccine. This applies to 1 of 5 residents (R113) reviewed for immunizations in the sample of 25.
  8. D
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 25, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a splint was applied to a resident's left hand contracture for 1 of 2 residents (R11) reviewed for splints in the sample of 25.
  9. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 25, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were supervised while smoking. The facility also failed to ensure residents with a risk for aspiration pneumonia were supervised while eating. This applies to 2 of 25 residents (R5 and R83) reviewed for safety/supervision in the sample of 25.
  10. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 25, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure incontinence care was performed in a manner to prevent infections and failed to ensure indwelling urinary catheter bags were kept below the level of the bladder and off of the ground to prevent infection for 3 of 9 residents (R24, R103 and R158) reviewed for incontinence care and catheters in the sample of 25.
  11. D
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 25, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications as ordered. There were 24 opportunities with 7 errors resulting in a 24.14% error rate. This applies to 2 of 9 residents (R105, R113) observed in the medication pass.
  12. D
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 25, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to label a multi dose insulin pen with an open and/or expiration date for one of one resident (R32) reviewed for medication labeling in the sample of 25.
  13. D
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 25, 2024
    Inspectors wroteBased on interview and record review the facility failed to offer residents the pneumonia vaccine. This applies to 3 of 5 residents (R22, R82 and R113) reviewed for immunizations in the sample of 25.
June 10, 2024Complaint inspection · 3 citations
  1. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 20, 2024
    Inspectors wroteBased on interview and record review, the facility failed to notify a resident's (R1) representative of a change in condition and need to alter treatment. This applies to 1 of 5 residents reviewed for change in condition in the sample of 5.
  2. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 20, 2024
    Inspectors wroteBased on interview and record review, the facility failed to protect 2 residents (R2, R3) from physical abuse by another resident. This applies to 2 of 5 residents reviewed for abuse in the sample of 5.
  3. D
    Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
    F740 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 20, 2024
    Inspectors wroteBased on interview and record review, the facility failed to monitor, document, and respond to behaviors for 1 of 5 residents (R1) reviewed for behavior management in the sample of 5.
January 31, 2024Complaint inspection · 1 citation
  1. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 7, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) care for a dependent resident. This applies to 1 of 3 residents (R1) reviewed for ADLs in the sample of 4.
October 31, 2023Complaint inspection · 1 citation
  1. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) November 3, 2023
    Inspectors wroteBased on interview and record review the facility failed to ensure food temperatures were obtained prior to serving the meals. This failure has the potential to affect all 122 residents residing in the facility.
October 11, 2023Complaint inspection · 2 citations
  1. D
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 20, 2023
    Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a homelike environment. This applies to 1 of 4 residents (R1) reviewed for homelike environment in the sample of 17.
  2. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 20, 2023
    Inspectors wroteBased on interview and record review the facility failed to ensure neurological assessments were done after a fall for 1 of 3 residents (R1) reviewed for post fall care in the sample of 17.
June 13, 2023Standard inspection · 6 citations
  1. F
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) June 27, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired medications. This failure has the potential to affect all residents in the facility.
  2. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 27, 2023
    Inspectors wroteBased on observation, interview and record review the facility failed to communicate a resident change in condition to the Physician and to other staff in the facility. This facility failure resulted in R70 being fed a meal when he could not safely swallow the food. This applies to one of one resident (R70) reviewed for notification in the sample of 23.
  3. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 27, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to perform surgical wound care in a manner to prevent infection for 1 of 1 resident (R325) reviewed for non-pressure skin care in the sample of 23.
  4. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 27, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to perform urinary catheter care in a manner to prevent infection for 1 of 5 residents (R88) reviewed for urinary catheters in the sample of 23.
  5. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 27, 2023
    Inspectors wroteBased on interview and record review, the facility failed to identify a significant weight loss for a resident (R109) receiving dialysis. This applies to 1 of 4 residents reviewed for dialysis in the sample of 23.
  6. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 27, 2023
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure incontinent care was provided in a manner to prevent cross-contamination for 1 of 8 residents (R45) reviewed for infection control in the sample of 23.

Fire safety inspections

3 fire safety citations on file: 1 on July 10, 2024, 2 on June 13, 2023.

Every fire safety citation3 citations
  1. F
    Address subsistence needs for staff and patients.
    E 15 · July 10, 2024 · Corrected (the home has a date of correction)
  2. F
    Establish roles under a Waiver declared by secretary.
    E 26 · June 13, 2023 · Corrected (the home has a date of correction)
  3. F
    Provide family notifications of emergency plan.
    E 35 · June 13, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
July 10, 2024Fine $21,212

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeIllinoisUnited States
All nursing staff (RN, LPN and aides)3.703.453.86
Registered nurses0.620.720.69
All nursing staff on weekends3.473.073.42
Nurse aides2.23
Licensed practical nurses0.85
Nursing staff turnover (share who left in a year)59.6%44.5%45.8%
Registered nurse turnover53.8%41.8%42.9%
Administrators who left0

CMS expects 4.67 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.80 on weekdays and 3.47 on weekends, 9% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.34 in April to June 2025 to 3.70 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.700.623.803.47 1.0%0 of 90120
Oct to Dec 20253.590.603.683.36 1.0%0 of 92124
Jul to Sep 20253.550.643.653.30 1.0%0 of 92125
Apr to Jun 20253.340.613.453.08 0.8%0 of 91121
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Illinois, Jan to Mar 20263.260.653.402.925.4%0.6% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Illinois

JobMedianMiddle halfEmployed
Illinois, all employers
CNAs (nursing assistants)$22.10$18.95 to $23.2668,640
LPNs and LVNs$36.06$30.57 to $38.2517,440
Registered nurses$46.15$38.47 to $50.94138,910
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

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For Pa Peterson at the Citadel. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

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Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeIllinoisUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
12.713.413.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.50.90.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.61.51.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
2.73.13.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
1.62.21.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
19.114.314.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
7.74.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
31.121.715.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
22.126.123.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
6.113.812.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.92.01.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
0.62.21.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Pa Peterson at the Citadel's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (46.0% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

46.0% this home

No different from the national rate

US median of homes 51.5% · Illinois: 106 better, 85 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 168 eligible stays.

Potentially preventable readmissions

11.4% this home

No different from the national rate

US median of homes 10.7% · Illinois: 2 better, 14 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 154 eligible stays.

Infections that led to a hospital stay

8.3% this home

No different from the national rate

US median of homes 7.1% · Illinois: 3 better, 10 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 87 eligible stays.

Self-care and mobility at discharge

62.1% this home

Median of homes: Illinois50.0% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 66 residents counted.

Falls with major injury

0.0% this home

Median of homes: Illinois0.3% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 118 residents counted.

New or worsened pressure ulcers

1.3% this home

Median of homes: Illinois1.5% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 118 residents counted.

Medication list given at discharge

98.2% this home

Median of homes: Illinois100.0% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 54 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: PA PETERSON AT THE CITADEL LLC. CMS links this home to Citadel Healthcare, a group of 16 nursing homes averaging 2.9 stars overall.

NameRoleTypeShareSince
Kohen, Tsipporah5% or greater direct ownership interestIndividual5%06/30/2017
Ripstein, KennethCorporate officerIndividual06/30/2017
Aaron, JonathanOperational/managerial controlIndividual01/06/2025
Graf, MarcellaOperational/managerial controlIndividual06/30/2017
Michalsen, ThomasOperational/managerial controlIndividual03/10/2025
Rhoe, MichaelOperational/managerial controlIndividual12/31/1999
Ripstein, KennethOperational/managerial controlIndividual06/30/2017
Aaron, JonathanAdp of the SNFIndividual01/06/2025
Michalsen, ThomasAdp of the SNFIndividual03/10/2025
Rhoe, MichaelAdp of the SNFIndividual12/14/2020
Ripstein, KennethAdp of the SNFIndividual01/06/2025

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 30 problems in this area, most recently on June 25, 2026: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
  2. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 10 problems in this area, most recently on July 7, 2026: "Protect each resident from the wrongful use of the resident's belongings or money."
  3. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 9 problems in this area, most recently on December 2, 2025: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist."
  4. What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 7 problems in this area, most recently on May 21, 2025: "Provide and implement an infection prevention and control program."

Other nursing homes nearby

Illinois contacts for a concern about a nursing home

These are the official offices in Illinois. NursingHomeClear cannot take or act on complaints.

Common questions

What is Pa Peterson at the Citadel's Medicare star rating?
CMS rates Pa Peterson at the Citadel 1 out of 5 stars overall, with 2 for health inspections, 1 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Pa Peterson at the Citadel get at its last inspection?
12 health deficiencies at the standard inspection on May 21, 2025. The Illinois average is 12.6.
Has Pa Peterson at the Citadel been fined?
Yes. CMS lists 1 fine totaling $21,212 in the last three years.
Does Pa Peterson at the Citadel accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Pa Peterson at the Citadel?
CMS lists 11 owners and managers, and links the home to Citadel Healthcare. Legal business name: PA PETERSON AT THE CITADEL LLC.

Sources

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