PA PETERSON AT THE CITADEL
PA PETERSON AT THE CITADEL is a 129-bed nursing home in ROCKFORD, Illinois. CMS has certified it for Medicare and Medicaid since 1993-09-01. It averages 119.6 residents a day.
What harm was found in the violations cited at PA PETERSON AT THE CITADEL?
CMS lists 65 health-inspection deficiencies for PA PETERSON AT THE CITADEL since 2023-06-13, 59 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is G; the most recent health inspection was 2026-06-25.
| Survey date | Tag | Deficiency | Severity |
|---|---|---|---|
| 2026-06-25 | F0600, F0686 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D |
| 2026-04-03 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D |
| 2026-03-02 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D |
| 2025-12-02 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D |
| 2025-11-24 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D |
| 2025-05-21 | F0684, F0725, F0880 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / Provide and implement an infection prevention and control program. | E |
| 2025-05-21 | F0550, F0605, F0677, F0686, F0688, F0689, F0695, F0761, F0883, F0610 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide safe and appropriate respiratory care for a resident when needed. / 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. / Develop and implement policies and procedures for flu and pneumonia vaccinations. / Respond appropriately to all alleged violations. | D |
| 2024-12-13 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D |
| 2024-12-10 | F0584 | 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. | D |
| 2024-11-19 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E |
| 2024-11-19 | F0602, F0609, F0610, F0761 | Protect each resident from the wrongful use of the resident's belongings or money. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / 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. | D |
| 2024-10-18 | F0607, F0609 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D |
| 2024-10-16 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D |
| 2024-10-07 | F0684, F0692 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide enough food/fluids to maintain a resident's health. | D |
| 2024-09-24 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D |
| 2024-09-12 | F0684, F0695, F0755 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide safe and appropriate respiratory care for a resident when needed. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D |
| 2024-08-30 | F0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | D |
| 2024-08-20 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D |
| 2024-07-18 | F0880 | Provide and implement an infection prevention and control program. | E |
| 2024-07-10 | F0684, F0686, F0692 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide enough food/fluids to maintain a resident's health. | G |
| 2024-07-10 | F0803 | 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. | F |
| 2024-07-10 | F0677, F0880, F0887 | Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide and implement an infection prevention and control program. / 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. | E |
| 2024-07-10 | F0688, F0689, F0690, F0759, F0761, F0883 | 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Ensure medication error rates are not 5 percent or greater. / 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. / Develop and implement policies and procedures for flu and pneumonia vaccinations. | D |
| 2024-06-10 | F0580, F0600, F0740 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | D |
| 2024-01-31 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D |
| 2023-10-31 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F |
| 2023-10-11 | F0584, F0684 | 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. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D |
| 2023-08-09 | F0584 | 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. | D |
| 2023-06-13 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | F |
| 2023-06-13 | F0580, F0684, F0690, F0698, F0880 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Provide safe, appropriate dialysis care/services for a resident who requires such services. / Provide and implement an infection prevention and control program. | D |
Why was PA PETERSON AT THE CITADEL fined?
| Date | Type | Amount |
|---|---|---|
| 2024-07-10 | Fine | $21,212 |
How is PA PETERSON AT THE CITADEL staffed?
| Measure | This facility | IL average |
|---|---|---|
| Total nurse staffing hours per resident per day | 3.70282 | 3.44603 |
| Total nursing staff turnover (%) | 59.6 | 44.5 |
| Average number of residents per day | 119.6 | 95.4 |
Who owns PA PETERSON AT THE CITADEL, and what chain is it in?
PA PETERSON AT THE CITADEL is registered with CMS as For profit - Partnership, operates under the legal business name PA PETERSON AT THE CITADEL LLC and belongs to the CITADEL HEALTHCARE chain.
| Role | Owner | Association date |
|---|---|---|
| 5% OR GREATER DIRECT OWNERSHIP INTEREST | KOHEN, TSIPPORAH | since 06/30/2017 |
| CORPORATE OFFICER | RIPSTEIN, KENNETH | since 06/30/2017 |
| OPERATIONAL/MANAGERIAL CONTROL | AARON, JONATHAN, GRAF, MARCELLA, MICHALSEN, THOMAS, RHOE, MICHAEL, RIPSTEIN, KENNETH | since 01/06/2025 |
| ADP OF THE SNF | AARON, JONATHAN, MICHALSEN, THOMAS, RHOE, MICHAEL, RIPSTEIN, KENNETH | since 01/06/2025 |
Were you or a family member harmed at PA PETERSON AT THE CITADEL?