Nursing homeActive
Pa Peterson At The Citadel
1311 Parkview Avenue, Rockford, IL 611078153998832129 certified beds · 120 residentsFor profit - PartnershipMedicare and Medicaid
Surveys on file
24
since 2023
Deficiencies
65
● 0● 62● 3
Penalties · 3 yrs
$21,212
1 fine
Last survey
2026-06-25
Complaint
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 2
Staffing 1
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Illinois Department of Public Health · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-06-25 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2026-04-03 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2026-03-02 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-12-02 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-11-24 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-05-21 | Standard | 0130 | CMS-2567 (Care Compare) | — |
| 2024-12-13 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-12-10 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-11-19 | Complaint | 050 | CMS-2567 (Care Compare) | — |
| 2024-10-18 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-10-16 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-10-07 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-09-24 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-09-12 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2024-08-30 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-08-20 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-07-18 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-07-10 | Standard | 0103 | CMS-2567 (Care Compare) | — |
| 2024-06-10 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2024-01-31 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-10-31 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-10-11 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2023-08-09 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-06-13 | Standard | 060 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Illinois Department of Public Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-02Record 145751-20260625-F600
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-07-02Record 145751-20260625-F686
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-04-08Record 145751-20260403-F689
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-05Record 145751-20260302-F686
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-05Record 145751-20251202-F755
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-04Record 145751-20251124-F689
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 145751-20250521-F550
F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 145751-20250521-F605
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 145751-20250521-F610
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 145751-20250521-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 145751-20250521-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 145751-20250521-F686
F688Provide 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 145751-20250521-F688
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 145751-20250521-F689
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 145751-20250521-F695
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 145751-20250521-F725
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 145751-20250521-F761
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 145751-20250521-F880
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-30Record 145751-20250521-F883
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-19Record 145751-20241213-F677
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-12-17Record 145751-20241210-F584
F602Protect each resident from the wrongful use of the resident's belongings or money.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-29Record 145751-20241119-F602
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-29Record 145751-20241119-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-29Record 145751-20241119-F610
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-11-29Record 145751-20241119-F755
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-11-29Record 145751-20241119-F761
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-29Record 145751-20241018-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-29Record 145751-20241018-F609
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-29Record 145751-20241016-F580
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-29Record 145751-20241007-F684
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-29Record 145751-20241007-F692
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-07Record 145751-20240924-F755
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-18Record 145751-20240912-F684
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-18Record 145751-20240912-F695
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-18Record 145751-20240912-F755
F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-10Record 145751-20240830-F744
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-04Record 145751-20240820-F684
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-29Record 145751-20240718-F880
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-07-25Record 145751-20240710-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-07-25Record 145751-20240710-F686
F692Provide enough food/fluids to maintain a resident's health.Scope/severity GHarm
Care planning
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-07-25Record 145751-20240710-F692
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-25Record 145751-20240710-F677
F688Provide 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-25Record 145751-20240710-F688
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-25Record 145751-20240710-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-25Record 145751-20240710-F690
F759Ensure medication error rates are not 5 percent or greater.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-25Record 145751-20240710-F759
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-25Record 145751-20240710-F761
F803Ensure 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.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-07-25Record 145751-20240710-F803
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-29Record 145751-20240710-F880
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-25Record 145751-20240710-F883
F887Educate 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.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-25Record 145751-20240710-F887
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-20Record 145751-20240610-F580
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-20Record 145751-20240610-F600
F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-20Record 145751-20240610-F740
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-02-07Record 145751-20240131-F677
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-11-03Record 145751-20231031-F812
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-20Record 145751-20231011-F584
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-20Record 145751-20231011-F684
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-21Record 145751-20230809-F584
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-06-27Record 145751-20230613-F580
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-06-27Record 145751-20230613-F684
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-06-27Record 145751-20230613-F690
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-06-27Record 145751-20230613-F698
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity FStandard
Medication
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-06-27Record 145751-20230613-F755
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-06-27Record 145751-20230613-F880
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2024-07-10 | Civil money penalty | $21,212 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.62
Facility
Illinois
National
Illinois 0.72 · National 0.69
Total nurse hours per resident day3.70
Facility
Illinois
National
Illinois 3.45 · National 3.86
Weekend total nurse hours3.47
Facility
Illinois
National
Illinois 3.08 · National 3.42
Total nursing staff turnover60%
Facility
Illinois
National
Illinois 45% · National 46%
Registered nurse turnover54%
Facility
Illinois
National
Illinois 42% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Illinois | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 7.7% | 4.8% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 2.7% | 3.1% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 31.0% | 21.7% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.6% | 1.5% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 12.7% | 13.4% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 11.7% | 6.3% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 14.2% | 18.3% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Kohen, Tsipporah Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 5% | — | — |
| 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 | — | — |
| Aaron, Jonathan Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Michalsen, Thomas Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Rhoe, Michael Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Ripstein, Kenneth Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Ripstein, Kenneth Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
Citadel Healthcare — 14 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Illinois.
No county cost figures on file for Winnebago.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| The Citadel at Saint Anne Place Rockford | 1.4 mi | 2026-06-23 | 0288 |
| Rock River Health Care Rockford | 2.5 mi | 2026-06-02 | 0415 |
| Avira Health Pavilion Loves Park | 2.6 mi | 2026-03-17 | 0160 |
| Fairhaven Christian Ret Center Rockford | 2.5 mi | 2026-02-26 | 0154 |
| Amberwood Care Centre Rockford | 2.3 mi | 2026-02-25 | 0180 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |