Pa Peterson At The Citadel
PA PETERSON AT THE CITADEL in ROCKFORD, IL — inspection on November 24, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
without assistive devices due to R1's medical condition and safety concerns.
On 11/24/25 at 11:40 AM, V5 (R1's Family Member) said R1 was admitted to the facility from a local hospital after R1 became unable to walk with pain in R1's left hip from osteoarthritis.
On 11/24/25 at 11:20 AM, V3 (Receptionist) said on the evening of 11/2/25, V3 saw R1 self-propel in a wheelchair from the elevator, approximately fifteen feet towards the main lobby. V3 said R1 had called out for help, but nursing staff could not hear R1. V3 asked R1 if V3 could help and R1 had requested V3 bring R1 to the window to wait for V5 to arrive at the facility.
When V5 arrived, R1 requested V3 to bring R1 out the front doors to greet V5. V3 said the main front door has two doors. V3 said V3 had wheeled R1 out of the first door and the second door began to close on R1 and V3. V3 then positioned herself to prop open the entrance door with one arm and used the other arm to assist R1 out of the doorway. V3 said when R1 was completely out of the doorway, V3 saw V5 at the bottom of the sidewalk, let go of the wheelchair without ensuring R1 had 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 R1's wheelchair. V3 then went to turn around and go back inside when R1 uncontrollably wheeled down the sidewalk, eventually falling forward from R1's wheelchair and scraping 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 R1's wheelchair brakes were engaged or that R1's wheelchair was on a more level surface before letting go of 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 R1's feet were on the ground or that R1's wheelchair brakes were engaged before letting go of R1's wheelchair.
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