PA Peterson at the Citadel

Nursing Home · Rockford, IL

CMS overall rating 1/5 Abuse citation For profit - Partnership

CMS certification number145751
This facility was cited for abuse, neglect or exploitation in a recent inspection (CMS abuse icon).

Contact & location

1311 Parkview Avenue
Rockford, IL 61107
Winnebago County
Phone
(815) 399-8832
ZIP code
61107 – all care providers

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Facility details

Certified beds
129
Residents per day
119.6 (93% occupied)
Ownership
For profit - Partnership
Legal name
PA Peterson at the Citadel LLC
Chain
Citadel Healthcare (14 facilities, avg 3.2★)
Medicare certified since
September 1, 1993
Participates in
Medicare and Medicaid
Continuing care
Part of a continuing care retirement community
Council
Resident council

CMS star ratings

Overall★★★★★ 1/5
State avg 2.5
Health inspections★★★★★ 2/5
State avg 2.7
Staffing★★★★★ 1/5
State avg 2.1
Quality measures★★★★★ 4/5
State avg 3.0
Long-stay quality★★★★★ 4/5
Short-stay quality★★★★★ 4/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
3.70 (state 3.45 · U.S. 3.86)
Registered nurses (RN)
0.62 (state 0.72 · U.S. 0.69)
Licensed practical nurses
0.85 (state 0.64 · U.S. 0.86)
Nurse aides
2.23 (state 2.09 · U.S. 2.32)
Weekend total
3.47 (state 3.08 · U.S. 3.42)
Nursing staff turnover
59.6 (state 44.5 · U.S. 45.8)%
RN turnover
53.8 (state 41.8 · U.S. 42.9)%
Administrators who left
0 in the last year

Inspections

Last standard inspection
May 21, 2025
Health deficiencies (last cycle)
18.0 (state 12.5 · U.S. 9.3)
From complaints
6
Citations on record (3 years)
65 health · 3 fire safety · includes actual harm
DateCitationSeverityStatus
2026-06-25 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-07-02
2026-06-25 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-07-02
2026-04-03 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-08
2026-03-02 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-03-05
2025-12-02 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-05
2025-11-24 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-04
2025-05-21 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-05-30
2025-05-21 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F0725 · Nursing and Physician Services Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-05-30
2025-05-21 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-05-30
2025-05-21 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F0550 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-30
2025-05-21 Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
F0605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-30
2025-05-21 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-30
2025-05-21 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-30
2025-05-21 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.
F0688 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-30
2025-05-21 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-30
2025-05-21 Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-30
2025-05-21 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.
F0761 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-30
2025-05-21 Develop and implement policies and procedures for flu and pneumonia vaccinations.
F0883 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-30
2025-05-21 Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-05-30
2024-12-13 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-12-19
2024-12-10 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.
F0584 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-12-17
2024-11-19 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-11-29
2024-11-19 Protect each resident from the wrongful use of the resident's belongings or money.
F0602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-11-29
2024-11-19 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-11-29
2024-11-19 Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-11-29
2024-11-19 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.
F0761 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-11-29
2024-10-18 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-10-29
2024-10-18 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-10-29
2024-10-16 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-10-29
2024-10-07 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-10-29
2024-10-07 Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-10-29
2024-09-24 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-10-07
2024-09-12 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-09-18
2024-09-12 Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-09-18
2024-09-12 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-09-18
2024-08-30 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
F0744 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-09-10
2024-08-20 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-09-04
2024-07-18 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-07-29
2024-07-10 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies		 G
Actual harm		 Corrected 2024-07-25
2024-07-10 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies		 G
Actual harm		 Corrected 2024-07-25
2024-07-10 Provide enough food/fluids to maintain a resident's health.
F0692 · Quality of Life and Care Deficiencies		 G
Actual harm		 Corrected 2024-07-25
2024-07-10 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.
F0803 · Nutrition and Dietary Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2024-07-25
2024-07-10 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-07-25
2024-07-10 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-07-29
2024-07-10 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.
F0887 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-07-25
2024-07-10 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.
F0688 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-07-25
2024-07-10 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-07-25
2024-07-10 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F0690 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-07-25
2024-07-10 Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-07-25
2024-07-10 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.
F0761 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-07-25

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

1 penalty in the last three years, including $21,212 in fines.

DateTypeAmount
2024-07-10Fine$21,212

Ownership & management

NameRoleSince
Kohen, Tsipporah (individual)5%+ Direct Ownership Interest · 5%
Aaron, Jonathan (individual)Administrator · NOT APPLICABLE
Michalsen, Thomas (individual)Administrator · NOT APPLICABLE
Rhoe, Michael (individual)Administrator · NOT APPLICABLE
Ripstein, Kenneth (individual)Administrator · NOT APPLICABLE
Ripstein, Kenneth (individual)Corporate Officer · NOT APPLICABLE
Aaron, Jonathan (individual)Operational/managerial Control · NOT APPLICABLE
Graf, Marcella (individual)Operational/managerial Control · NOT APPLICABLE
Michalsen, Thomas (individual)Operational/managerial Control · NOT APPLICABLE
Rhoe, Michael (individual)Operational/managerial Control · NOT APPLICABLE
Ripstein, Kenneth (individual)Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of PA Peterson at the Citadel?

PA Peterson at the Citadel has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 2.5-star average in Illinois.

How many beds does PA Peterson at the Citadel have?

It has 129 certified beds and cares for about 120 residents per day.

Has PA Peterson at the Citadel been fined?

Yes. CMS lists 1 penalty totaling $21,212 in the last three years.

Who owns PA Peterson at the Citadel?

It is part of Citadel Healthcare and is classified as for profit - partnership. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of PA Peterson at the Citadel?

(815) 399-8832. The facility is located at 1311 Parkview Avenue, Rockford, IL 61107.

Other nursing homes in Rockford

Compare all nursing homes in Rockford, IL →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.