Facility Watch Inspection records for every certified US nursing home

PA Peterson at the Citadel

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

CCN
145751
Certified beds
129
Ownership
For profit - Partnership
Chain
Citadel Healthcare

Nurse staffing

2.84
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.48 hours per resident per day

Nursing staff turnover: 55% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected April 3, 2026

1 citation · from a complaint investigation · Health
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected April 8, 2026

Inspected March 2, 2026

1 citation · from a complaint investigation · Health
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected March 5, 2026

Inspected December 2, 2025

1 citation · from a complaint investigation · Health
D
F0755 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected December 5, 2025

Inspected November 24, 2025

1 citation · from a complaint investigation · Health
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected December 4, 2025

Inspected May 21, 2025

13 citations · from a complaint investigation · Health
D
F0550 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected May 30, 2025
D
F0605 No actual harm with potential for more than minimal harm · Isolated

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Deficient, Provider has date of correction · corrected May 30, 2025
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected May 30, 2025
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected May 30, 2025
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected May 30, 2025
D
F0688 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected May 30, 2025
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected May 30, 2025
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected May 30, 2025
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected May 30, 2025
D
F0883 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Deficient, Provider has date of correction · corrected May 30, 2025
E
F0684 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected May 30, 2025
E
F0725 No actual harm with potential for more than minimal harm · Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected May 30, 2025
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected May 30, 2025

Inspected December 13, 2024

1 citation · from a complaint investigation · Health
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected December 19, 2024

Inspected December 10, 2024

1 citation · from a complaint investigation · Health
D
F0584 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected December 17, 2024

Inspected November 19, 2024

5 citations · from a complaint investigation · Health
D
F0602 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from the wrongful use of the resident's belongings or money.

Deficient, Provider has date of correction · corrected November 29, 2024
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected November 29, 2024
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected November 29, 2024
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected November 29, 2024
E
F0755 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected November 29, 2024

Inspected October 18, 2024

2 citations · from a complaint investigation · Health
D
F0607 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Deficient, Provider has date of correction · corrected October 29, 2024
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected October 29, 2024

Inspected October 16, 2024

1 citation · from a complaint investigation · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected October 29, 2024

Inspected October 7, 2024

2 citations · from a complaint investigation · Health
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected October 29, 2024
D
F0692 No actual harm with potential for more than minimal harm · Isolated

Provide enough food/fluids to maintain a resident's health.

Deficient, Provider has date of correction · corrected October 29, 2024

Inspected September 24, 2024

1 citation · from a complaint investigation · Health
D
F0755 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected October 7, 2024

Inspected September 12, 2024

3 citations · from a complaint investigation · Health
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected September 18, 2024
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected September 18, 2024
D
F0755 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected September 18, 2024

Inspected August 30, 2024

1 citation · from a complaint investigation · Health
D
F0744 No actual harm with potential for more than minimal harm · Isolated

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Deficient, Provider has date of correction · corrected September 10, 2024

Inspected August 20, 2024

1 citation · from a complaint investigation · Health
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected September 4, 2024

Inspected July 18, 2024

1 citation · from a complaint investigation · Health
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected July 29, 2024

Inspected July 10, 2024

13 citations · Health
D
F0688 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected July 25, 2024
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected July 25, 2024
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected July 25, 2024
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected July 25, 2024
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected July 25, 2024
D
F0883 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Deficient, Provider has date of correction · corrected July 25, 2024
E
F0677 No actual harm with potential for more than minimal harm · Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected July 25, 2024
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected July 29, 2024
E
F0887 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected July 25, 2024
F
F0803 No actual harm with potential for more than minimal harm · Widespread

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.

Deficient, Provider has date of correction · corrected July 25, 2024
G
F0684 Actual harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected July 25, 2024
G
F0686 Actual harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected July 25, 2024
G
F0692 Actual harm · Isolated

Provide enough food/fluids to maintain a resident's health.

Deficient, Provider has date of correction · corrected July 25, 2024

Inspected June 10, 2024

3 citations · from a complaint investigation · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected June 20, 2024
D
F0600 No actual harm with potential for more than minimal harm · Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Deficient, Provider has date of correction · corrected June 20, 2024
D
F0740 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Deficient, Provider has date of correction · corrected June 20, 2024

Inspected January 31, 2024

1 citation · from a complaint investigation · Health
D
F0677 No actual harm with potential for more than minimal harm · Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Deficient, Provider has date of correction · corrected February 7, 2024

Inspected October 31, 2023

1 citation · from a complaint investigation · Health
F
F0812 No actual harm with potential for more than minimal harm · Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected November 3, 2023

Inspected October 11, 2023

2 citations · from a complaint investigation · Health
D
F0584 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected October 20, 2023
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected October 20, 2023

Inspected August 9, 2023

1 citation · from a complaint investigation · Health
D
F0584 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected August 21, 2023

Inspected June 13, 2023

6 citations · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected June 27, 2023
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected June 27, 2023
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected June 27, 2023
D
F0698 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected June 27, 2023
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected June 27, 2023
F
F0755 No actual harm with potential for more than minimal harm · Widespread

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

Deficient, Provider has date of correction · corrected June 27, 2023

Penalties

DateTypeAmount
July 10, 2024Fine$21,212

Ownership transfers

EffectiveSellerBuyer
07/18/2017PA Peterson, LLCPA Peterson at the Citadel LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.