Pa Peterson At The Citadel
Inspection Findings
F-Tag F0689
F 0689
without assistive devices due to Resident R1's medical condition and safety concerns.
Level of Harm - Minimal harm or potential for actual harm
On 11/24/25 at 11:40 AM, V5 (Resident R1's Family Member) said Resident R1 was admitted to the facility from a local hospital after Resident R1 became unable to walk with pain in Resident R1's left hip from osteoarthritis.
Residents Affected - Few
On 11/24/25 at 11:20 AM, V3 (Receptionist) said on the evening of 11/2/25, V3 saw Resident R1 self-propel in a wheelchair from the elevator, approximately fifteen feet towards the main lobby. V3 said Resident R1 had called out for help, but nursing staff could not hear Resident R1. V3 asked Resident R1 if V3 could help and Resident R1 had requested V3 bring Resident R1 to the window to wait for V5 to arrive at the facility. When V5 arrived, Resident R1 requested V3 to bring Resident R1 out
the front doors to greet V5. V3 said the main front door has two doors. V3 said V3 had wheeled Resident R1 out of
the first door and the second door began to close on Resident R1 and V3. V3 then positioned herself to prop open
the entrance door with one arm and used the other arm to assist Resident R1 out of the doorway. V3 said when Resident R1 was completely out of the doorway, V3 saw V5 at the bottom of the sidewalk, let go of the wheelchair without ensuring Resident R1 had Resident R1's feet on the ground to prevent the wheelchair from going down the sloped sidewalk. V3 also said V3 did not engage the wheelchair brakes before letting go of Resident R1's wheelchair. V3 then went to turn around and go back inside when Resident R1 uncontrollably wheeled down the sidewalk, eventually falling forward from Resident R1's wheelchair and scraping Resident R1's knees on the sidewalk.
On 11/24/25 at 12:07 PM, V4 (Scheduling Coordinator) said once a wheelchair proceeds past the door threshold at the main door, it's almost an immediately downward slope towards the parking lot that would take the wheelchair down the slope by gravity without the resident having their feet on the ground or having staff assisting the wheelchair descend. V4 said V4 has an active certified nursing assistant license and V4 would have ensured Resident R1's wheelchair brakes were engaged or that Resident R1's wheelchair was on a more level surface before letting go of Resident R1's wheelchair.
On 11/24/25 at 1:10 PM, V14 (Assistant Director of Nursing) said in hindsight, after the event, V3 should have ensured either Resident R1's feet were on the ground or that Resident R1's wheelchair brakes were engaged before letting go of Resident R1's wheelchair.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
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If continuation sheet
PA PETERSON AT THE CITADEL in ROCKFORD, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ROCKFORD, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PA PETERSON AT THE CITADEL or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.