Peters Township Post Acute

Inspectors wroteBased on review of facility policy, resident observations, resident interviews and confidential staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of eight of eleven residents (Resident R1, R2, R3, R4, R5, R6, R7, and R8). Findings Include: Review of the facility policy Staffing dated 9/11/25, indicated Our facility provides adequate staffing to meet needed care and services for our resident population. Review of the facility policy Answering the Call Light dated 9/11/25, indicated the facility will ensure timely responses to the resident's requests and needs. During an interview on 4/6/26, at 12:40 p.m. [...]

Inspectors wroteBased on review of facility policy, facility provided documents, clinical records, and staff interviews, it was determined the facility failed to ensure a resident was free from mental abuse and intimidation for one of two residents reviewed (Resident R63), which resulted in psychosocial harm and mental anguish related to the reasonable person concept. Findings Include: Review of the facility policy Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated 9/11/25, with a previous review date of 1/20/25, indicated that the facility will document, investigate and report all reports of resident abuse; the Administrator determines what actions are needed to protect the resident involved. [...]

Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food, store food in accordance with professional standards for food service safety and failed to have food service staff wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food.

Inspectors wroteBased on review of facility policy, facility records, resident, and staff interviews, it was determined that the facility failed to make certain call lights were answered timely for ten of thirteen residents as required (Resident R31, R69, R115, R700, R703, R704, R706, R707, R708, and R709).

Inspectors wroteBased on observations, review of facility policy and staff interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment on two of three nursing units (Vintage and Heritage Nursing Units).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interviews it was determined that the facility failed to fully investigate allegations of physical/verbal abuse and an injury to one of three residents (Resident R63).

Inspectors wroteBased on review of facility policy, observation, and staff interviews, it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of two nursing floors.

Inspectors wroteBased on review of facility clinical records, observations and staff interview, it was determined that the facility failed to make certain that resident assessments were accurate for one of four residents (Resident R15).

Inspectors wroteBased on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly secure the Intravenous (IV) medication and supply cart for one of four carts observed (IV medication and supply cart).

Inspectors wroteBased on observations and a staff interview, it was determined the facility failed to post contact information, Adult Protective Services (APS), Medicaid Fraud Unit, and a statement the resident may file a complaint with the State Agency as required, in the building two of two locations where postings are located (first and second floor hallways).

Inspectors wroteBased on facility policy, clinical record review, resident and staff interviews, it was determined that the facility failed to make certain discharge planning is part of the resident care plan for one of five residents (Resident R1).

Inspectors wroteBased on a review of facility policy, federal regulation and staff interview, it was determined that the facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for eleven of 11 months (December 2023 and January, February, March, April, May, June, July, August, September, and October 2024).

Inspectors wroteBased on review of facility policy, review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to protect residents from an accident of a roll out of bed for one of three residents (Resident R1).

Inspectors wroteBased on review of resident clinical records, facility policy and staff interviews it was determined the facility failed to provide care and treatments related to dialysis care for one of two residents (Resident R10), and failed to provide consistent and complete communication with the dialysis center for two of two residents (Resident R10 and R245).

Inspectors wroteBased on observation, and staff interview, it was determined the facility failed to maintain a clean homelike environment for four of eight resident rooms (Resident room [ROOM NUMBER]B, room [ROOM NUMBER]B, room [ROOM NUMBER]B, and room [ROOM NUMBER]B). Findings Include: Review of the facility policy Accommodation of Needs last reviewed 10/4/23, indicated the residents are provided with a safe, clean, comfortable, and homelike environment. Review of the admission record indicated Resident R45 in room [ROOM NUMBER], was admitted to the facility on [DATE]. Observation of Resident R45's room [ROOM NUMBER] on 11/30/23, at 10:49 a.m. indicated the privacy curtain hanging in between the two resident beds was soiled with a brown substance on the entire lower half of the curtain. Review of the admission record indicated R12 in room [ROOM NUMBER]B was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policy, manufacturer's recommendations, observation, clinical record and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of two residents (Resident R45).

Inspectors wroteBased on a review of facility policy, resident interviews, staff interviews and observations it was determined the facility failed to provide the residents with food and drink that is palatable and at a safe and appetizing temperatures for two of two lunch meals observed (Lunch Meals on 11/29/23, on [NAME] Unit and Medbridge/TCU units).

Inspectors wroteBased on facility policies, observations and staff interviews, it was determined that the facility failed to perform hand washing to prevent the potential for cross contamination in the Main Kitchen and failed to perform handwashing between tasks in the main dining room during meal service.

Inspectors wroteBased on review of facility policy, observation, and staff interviews it was determined that the facility failed to follow proper infection control technique during a dressing change (Resident R298).