Pa Peterson at the Citadel
1311 Parkview Avenue · Rockford, IL · 61107 · 8153998832
129 certified beds For profit - Partnership Chain: Citadel Healthcare Part of a CCRC
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- 3 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 3 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.59 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.60 | 0.55–0.75 |
| Weekend hours / resident-day | 3.36 | ≈ weekday level |
| Nursing turnover / year | 55% | median 45% |
| Fines (3-yr window) | 1 · $21,212 |
Inspection citations (63 in the current record)
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Potential for harm · D April 3, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 8, 2026 · Quality of Life and Care
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Potential for harm · D March 2, 2026 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 5, 2026 · Quality of Life and Care
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Potential for harm · D December 2, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 5, 2025 · Pharmacy Service
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Potential for harm · D November 24, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 4, 2025 · Quality of Life and Care
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Potential for harm · D May 21, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected May 30, 2025 · Resident Rights
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Potential for harm · D May 21, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected May 30, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 21, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected May 30, 2025 · Quality of Life and Care
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Potential for harm · E May 21, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 30, 2025 · Quality of Life and Care
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Potential for harm · D May 21, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected May 30, 2025 · Quality of Life and Care
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Potential for harm · D May 21, 2025
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.
Corrected May 30, 2025 · Quality of Life and Care
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Potential for harm · D May 21, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 30, 2025 · Quality of Life and Care
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Potential for harm · D May 21, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected May 30, 2025 · Quality of Life and Care
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Potential for harm · E May 21, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected May 30, 2025 · Nursing and Physician Services
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Potential for harm · D May 21, 2025
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.
Corrected May 30, 2025 · Pharmacy Service
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Potential for harm · E May 21, 2025
Provide and implement an infection prevention and control program.
Corrected May 30, 2025 · Infection Control
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Potential for harm · D May 21, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected May 30, 2025 · Infection Control
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Potential for harm · D May 21, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected May 30, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 13, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected December 19, 2024 · Quality of Life and Care
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Potential for harm · D December 10, 2024 · found via complaint
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.
Corrected December 17, 2024 · Resident Rights
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Potential for harm · D November 19, 2024 · found via complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected November 29, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 19, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected November 29, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 19, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected November 29, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E November 19, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected November 29, 2024 · Pharmacy Service
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Potential for harm · D November 19, 2024 · found via complaint
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.
Corrected November 29, 2024 · Pharmacy Service
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Potential for harm · D October 18, 2024 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected October 29, 2024 · Freedom from Abuse, Neglect, and Exploitation
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| July 10, 2024 | Fine | $21,212 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145751 · certified since September 1, 1993. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.