PA Peterson at the Citadel Abuse and Neglect Attorneys

PA Peterson at the CitadelDo you suspect that your loved one has been mistreated, neglected or abused while residing in a Winnebago County nursing facility? If so, contact the Illinois Nursing Home Law Center Attorneys for immediate legal intervention. Our team of Illinois lawyers has successfully resolve cases just like yours.

Let us begin working on your claim today to ensure that your family is adequately compensated for your monetary damages. We will use the law to hold those responsible for causing your loved one harm both legally and financially accountable.

PA Peterson at the Citadel

This facility is a 129-certified bed "for profit" long term care home providing services and cares to residents of Rockford and Winnebago County, Illinois. The Medicare/Medicaid-participating long-term care (LTC) center is located at:

1311 Parkview Avenue
Rockford, Illinois, 61107
(815) 399-8832

In addition to providing around-the-clock skilled nursing care, PA Peterson at the Citadel Nursing Home offers other services that include:

  • Premier orthopedic rehab
  • Short-term rehabilitation
  • Pulmonary care
  • Stroke recovery care
  • Wound care
  • Pain management
  • Long-term care
  • Orthopedic care
  • Cardiac care
  • Outpatient therapy
  • Hospice care
  • Palliative care
  • Post-surgery care
Financial Penalties and Violations

It is the legal responsibility of Illinois and federal government investigators to hold nursing homes accountable if they have violated rules and regulations that harmed or could have harmed a resident. These penalties include monetary fines and denial of payment for Medicare services.

Within the last three years, PA Peterson at the Citadel Nursing Home has received thirty-four formally filed complaints due to substandard care. Additional information about fines and penalties can be reviewed on the Illinois Department of Public Health Nursing Home Reporting Website concerning this nursing facility.

Rockford Illinois Nursing Home Safety Concerns One Star Rating

Comprehensive research results can be reviewed on the Illinois Department of Public Health and Medicare.gov nursing home publically-available database systems. The sites detail all dangerous hazards, opened investigations, health violations, safety concerns, filed complaints, and incident inquiries. Many families use this information to determine the level of medical, health and hygiene care long-term care facilities in the local community provide their residents.

According to Medicare, this facility maintains an overall rating of one out of five stars, including one out of five stars concerning health inspections, three out of five stars for staffing issues and three out of five stars for quality measures. The Winnebago County neglect attorneys at Nursing Home Law Center have found serious deficiencies and safety concerns at PA Peterson at the Citadel that include:

  • Failure to Ensure Residents Receive Proper Treatment and Care to Prevent the Development of New Pressure Sores or Allow Existing Pressure Sores to Heal
  • In a summary statement of deficiencies dated April 13, 2018, the state investigators documented that the facility had failed to “ensure pressure relieving interventions were in place, failed to ensure a physician ordered dressing was in place on a pressure ulcer and failed to identify an area of pressure [before it developed] into an unstageable pressure ulcer.”

    The surveyors noted that this failure applies to two “residents reviewed for pressure ulcers.” One incident involved a review of a moderately cognitively impaired resident whose MDS (Minimum Data Set) Assessment reads “requires extensive staff assistance for bed mobility, transfers, personal hygiene, and toileting.” The documentation shows that the resident “is incontinent of urine and bowel.”

    Failure to follow protocols that prevent the development of bedsores – IL State Inspector

    A review of the resident’s Medical Records and Skin Impairment Care Plan revealed a “pressure injury left heel resolved.” The intervention included “the resident needs assistance to apply offloading protective boots, etc., and the resident needs a pressure reducing mattress, pillows for offloading, sheepskin padding, etc. to protect the skin while in bed.”

    The state survey team observed the resident “lying on her left side in bed. Two heel-protected boots were laying on the bedside table.” A few minutes later, a Certified Nursing Assistant (CNA) removed the patient’s “bed linens to perform peri-care [where the resident] had a dime size pressure ulcer on her right lower buttock. The pressure ulcer did not have a dressing covering it.”

    The CNA said that she had given the patient “a shower earlier in the morning and the dressing was falling off, so she completely removed it.” The CNA said that the resident “did have another pressure ulcer on her heel but she thought maybe it was closed now.” The CNA said the patient “should be wearing the heel protectors when in bed [and the] buttock wound should be covered at all times and aides should be reporting any missing or damaged dressing.”

    The CNA said that she did not report the patient’s “missing dressing because she thought the Wound Nurse was coming to assess the wound, but ‘I guess she never got here.’” When the CNA exited the resident’s room, the resident’s “uncovered buttock wound was exposed to the plastic bed mattress, and the heel protectors remained on the bedside table.”

  • Failure to Provide Every Resident an Environment Free of Accident Hazards and Provide Adequate Supervision to Prevent Avoidable Accidents
  • In a summary statement of deficiencies dated April 13, 2018, the state investigators documented that the facility failed to “ensure a resident with a high risk for falls had a call light within reach.” The investigator’s findings included a review of a moderately cognitively impaired resident’s MDS (Minimum Data Set) Assessment that shows the patient “requires extensive staff assistance for bed mobility, transfers, walking, dressing, personal hygiene, and toileting.” The documentation revealed that the resident “is incontinent of urine and bowel.”

    The resident’s Fall Care Plan provides a focus area stating that the patient “is at risk for falls related to a fall [before] admission” resulting in an injury. Interventions include “ensure the resident’s call light is within reach and encourage the resident to use it for assistance as needed. The resident needs a prompt response to all request for assistance. Anticipate and meet the resident’s needs.”

    The resident’s Incident Report revealed that they were “observed on the floor.” Observations of the resident reveal that the patient’s “call light was laying on the floor underneath the head of the bed [when the resident] was in light sleep and mobile that she wanted to get up.”

    The resident “was lying on her left side, and her feet were over the edge of the bed.” A few minutes later, the surveyor “was in the hallway one door down from [that resident’s] room and heard [the resident] moaning for assistance while saying, ‘Help me.’ The surveyor entered the room, and [the resident’s] legs were now over the left edge of the bed.”

    Approximately twenty minutes later, two Certified Nursing Aides entered the patient’s room. One CNA said, “Quick! Help me raise her up. Hurry, I need your help!” The CNA said that the resident “was trying to get out of bed alone just now. Both CNAs repositioned the patient “in bed [before one Certified Nursing Assistant] left the room.” The other CNA performed peri-care for the resident “and exited the room to assist the [another] resident down the hall.” That CNA left the resident “lying in bed, and the call light remains under the bed.”

    The state investigative team interviewed the Director of Nursing who said that “call light should be placed within the resident’s reach so that they can call for assistance.” The Director said that the “call light should be closed for all residents, even if they are confused residents.”

    The Director stated that “if residents cannot reach the call light there is the potential that they would try to move without the necessary assistance and end up falling.” The Director said that “Aides should always place the call light within reach after all resident care.”

    In a separate summary statement of deficiencies dated May 16, 2017, the state survey team noted that the nursing home had “failed to ensure the safety of residents on the secured dementia unit by not securing a door with access to an open window on the 3rd Floor.”

    The state survey team conducted an initial tour of the facility and found a door “unlocked on the east end of the 3rd Floor Dementia Unit. A window was open to the roof with no screen in place. There was a puddle of water on the windowsill which was directly above the wall heating unit.”

    The surveyors interviewed the Dementia Unit Director who said that “this room is known as the unit’s kitchen and that this door is to be locked.” The Director “turned the handle and entered the room without having to unlock the door.” and said that “I do not know why its unlocked right now.”

    During the interview, the Director “notice that the open window and the water that had accumulated on the windowsill [saying that] this should not be open. A bottle which was marked (glass cleaner) was noted to be on the countertop. However, the liquid inside the bottle was yellow, which was not the typical blue color of this brand of window cleaner.” The Director said that “she had no idea what chemicals were actually in the bottle and threw it in the trash can.”

    The facility Dementia Unit Licensed Practical Nurse (LPN) identified twelve “residents residing on the dementia unit who are ambulatory” and able to walk unassisted.

  • Failure to Provide and Implement an Infection Protection and Control Program
  • In a summary statement of deficiencies dated April 13, 2018, a state investigative team noted the nursing home's failure to “ensure gloves were changed during peri-care, failed to properly dispose of dirty linens, and failed to refill the resident dining items in a manner to prevent cross-contamination.”

  • Failure to Report and Investigate Any Act or Reports of Abuse, Neglect or Mistreatment of Residents
  • In a summary statement of deficiencies dated May 16, 2017, the state investigators documented that the nursing home had “failed to ensure allegations of abuse were immediately reported to the Administrator.” The investigators reviewed a written statement by a Licensed Practical Nurse (LPN) that documents “she was notified by an aide that [the resident] said her roommate was a man and he had raped her.” The LPN documented that the patient “had been refusing her medications.”

    The investigators interviewed the Administrator who stated that “she does not recall the exact time she was notified of the allegation,” but it was approximately “twelve hours after the allegation.” The Administrator said that “she should have been notified” earlier “when the allegation was initially reported to the nurse.”

    The preliminary Incident Investigation handled by the facility reported that the resident “was sent to the local emergency room for evaluation.” The Administrator said that “during the investigation, she found out [that the resident] had been refusing medication and had an acute psychotic episode.”

    The Administrator said that the resident “was admitted to the psychiatric unit for delusional behaviors.” The Administrator said that “this information was gathered during the investigation and shows why it is important for allegations to be immediately reported, and for staff to not interpret and abuse allegation on their own.”

  • Failure to Ensure Residents Receive Proper Treatment to Prevent New Bedsores or Heal Existing Pressure Sores
  • In a summary statement of deficiencies dated May 16, 2017, a state surveyor documented that the facility had failed to “implement pressure-relieving interventions.” This deficient practice by the nursing staff involved two residents “reviewed for pressure injuries.”

    The state investigative team reviewed a resident’s MDS (Minimum Data Set) Assessment that revealed the patient “is cognitively intact and requires extensive assistance from two or more staff members with transfers and repositioning in bed. The same MDS reveals that the [resident] is at risk for pressure ulcer development and has a stage III pressure ulcer. The MDS shows interventions check under the skin and ulcer treatment section including pressure reducing device for a chair, pressure reducing device for the bed, and a turning/repositioning program.”

    The resident’s Skin/Wound Progress Notes revealed that the resident has “a sacral wound measuring 4.3 cm x 4.5 cm x 2.2 cm, undermining 2.5 cm from 12/6 cm.”

    The state survey team observed the resident “lying in her bed with a pillow behind her left side. There was a sign posted on the wall above [the resident’s bed displaying] the 5-pillow rule, which listed the position for five individual pillows used to relieve pressure on [the patient’s] body. The sign also stated to reposition [the resident] every two hours side-to-side only please.”

    The investigators interviewed the resident who said that “they do not turn me every two hours and do not follow the 5-pillow rule.” The resident “did not have a pillow between her knees as listed on the sign.” The resident “had an air mattress on her bed.”

    The investigators interviewed the facility Director of Nursing who said that the facility expects “that Aides follow all interventions on resident care plans.” The Director said that “it is important to follow care plans to prevent a decline in health.”

Do You Need More Answers about PA Peterson at the Citadel Nursing Home? We Can Help

Have you concluded that your loved one was victimized by caregivers while living at PA Peterson at the Citadel Nursing Facility? If so, contact the Illinois nursing home abuse and neglect lawyers at Nursing Home Law Center at (800) 926-7565 today. Our network of attorneys fights aggressively on behalf of Winnebago County victims of mistreatment living in long-term facilities including nursing homes in Rockford. Contact us now to schedule a free case review to discuss how to obtain justice and resolve a financial compensation claim.

Our network of attorneys accepts all nursing home abuse lawsuits, personal injury claims, medical malpractice cases, and wrongful death suits through a contingency fee arrangement. This agreement postpones the requirement to make a payment to our network of attorneys until after we have successfully resolved your claim for compensation through a negotiated out of court settlement or jury trial award.

Our network of attorneys offers every client a “No Win/No-Fee” Guarantee, meaning if we are unable to resolve your case successfully, you owe us nothing. Let our network of attorneys start working on your case today to ensure your family receives the financial compensation they deserve for your harm. All information you share with our law offices will remain confidential.

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Client Reviews
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Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
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After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric