The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited July 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
Nursing home report
PA PETERSON AT THE CITADEL
ROCKFORD, IL · Medicare-certified · 129 beds
Needs attention
For-profitChain member
Data as of July 1, 2026
2 of 5 overall
PA Peterson at the Citadel has an overall rating of 2 out of 5 stars, with very weak staffing (1 star) and nurse staffing below the federal benchmark (3.70 vs. 4.1 hours per resident per day). It also has a recent federal penalty and $21,212 in fines over the last 24 months, while health inspection is 3 stars and quality measures are 4 stars.
Facility ratings
Health inspections
Staffing
3.7028 hrs/resident/day
Quality measures
Last inspection: April 3, 2026Penalties, last 24 months: $21,212recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.7028.
Staffing detail
- Registered nurses
- 0.62
- Licensed practical nurses
- 0.85
- Nurse aides
- 2.23
- Weekend nursing
- 3.47
Hours per resident per day.
Total staff turnover: 60%
Registered nurse turnover: 54%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
29.3%30.5%Worsening
Residents with a fall causing major injury
1.2%3.4%Worsening
Residents with pressure ulcers (bedsores)
6.3%8.1%Worsening
Residents with a urinary tract infection
1.2%0%Improving
Residents who lost too much weight
16.4%9%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
18.7%5.9%Improving
Residents whose ability to walk got worse
24%13.5%Improving
Long-stay residents on antianxiety or sleep medication
18.7%12.9%Improving
Short-stay residents newly given an antipsychotic
0.8%3.1%Worsening
Residents with a long-term catheter
0%1%Worsening
Residents with new or worsening incontinence
13.2%30.1%Worsening
Residents with depressive symptoms
95.2%94.1%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—62.1%—
Long-stay residents given the pneumonia vaccine
64%100%Improving
Short-stay residents given the seasonal flu vaccine
—31.6%—
Short-stay residents given the pneumonia vaccine
47%98.2%Improving
What the inspectors found
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited July 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 684 — 42 CFR §483.25 — S/S: G
The home failed to provide enough food and fluids to keep residents healthy. Cited July 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 692 — 42 CFR §483.25(g) — S/S: G
The home failed to ensure meals and menus were planned, updated, and followed to meet residents’ nutritional needs. Cited July 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 803 — 42 CFR §483.60 — S/S: F
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited October 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- PENALTY
A federal fine of $21,212 was recorded.
Penalties & enforcement
On record with Medicare: 1 fine · $21,212 in total fines.
- $21,212
Federal fine
Jul 10, 2024
Operator & ownership
Recent ownership change · Jul 18, 2017
Now operated by Pa Peterson at the Citadel, previously The Villa at Pa Peterson.
- Ownership
- For profit - Partnership
- Chain
- Part of CITADEL HEALTHCARE · 14 homes · 3.2 stars avg
- Occupancy
- 119.6 residents on an average day (93% of 129 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 32 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.