PA Peterson at the Citadel: Wheelchair Fall at Exit - IL
The incident happened on the evening of November 2, 2025, at PA Peterson at the Citadel. Federal inspectors documented it three weeks later during a complaint inspection on November 24.
The resident, identified in the inspection report only as R1, had been admitted to the facility from a local hospital after becoming unable to walk due to pain in the left hip from osteoarthritis. R1's family member told inspectors that R1 could not get around without assistive devices because of that condition.
That evening, R1 had self-propelled a wheelchair out of an elevator and about fifteen feet toward the main lobby, calling out for help along the way. Nursing staff couldn't hear. The receptionist, identified as V3, noticed and asked if she could help. R1 asked to be brought to the window to wait for a family member who was on the way.
When the family member arrived, R1 asked V3 to wheel R1 outside to greet them.
The main entrance has two doors. V3 got R1 through the first one, but the second door began to close on both of them. V3 used one arm to prop the door open and the other to help maneuver R1 through. Once R1 was clear of the doorway, V3 could see the family member at the bottom of the sidewalk.
Then V3 let go.
She hadn't put R1's feet on the footrests. She hadn't engaged the wheelchair brakes. She turned to go back inside. R1's wheelchair immediately began rolling down the slope, picked up speed, and R1 fell forward out of the chair, landing on the pavement and scraping both knees.
The facility's scheduling coordinator, V4, told inspectors she holds an active certified nursing assistant license and described the exit clearly: once a wheelchair crosses the front door threshold, the sidewalk drops at an angle steep enough that gravity alone will pull an unbraked chair toward the parking lot if no one is holding it and the resident's feet aren't on the ground. "V4 would have ensured R1's wheelchair brakes were engaged or that R1's wheelchair was on a more level surface before letting go," the inspection report states.
The assistant director of nursing told inspectors that, in hindsight, V3 should have made sure either the brakes were engaged or R1's feet were down before releasing the chair.
In hindsight. The slope had always been there.
CMS cited the facility under F0689, the tag covering accidents and supervision, finding that the facility failed to protect R1 from an accident that staff could have prevented. The level of harm was cited as minimal harm or potential for actual harm.
What the report doesn't resolve is why a receptionist was the one transporting a mobility-impaired resident to the exit at all. R1 had called out for nursing staff and gotten no answer. The person who responded was not a nurse, not an aide, not anyone trained in wheelchair safety as part of a clinical role. The scheduling coordinator, who does hold a nursing assistant license, described exactly what should have happened. She wasn't there.
R1's family member was standing at the bottom of that sidewalk when R1 came down it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pa Peterson At the Citadel from 2025-11-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PA PETERSON AT THE CITADEL in ROCKFORD, IL was cited for violations during a health inspection on November 24, 2025.
The incident happened on the evening of November 2, 2025, at PA Peterson at the Citadel.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.