Peterson Park Health Care Ctr

Inspectors wroteBased on interview and record review the facility failed to prevent resident to resident physical abuse for two (R1, R2) of seven residents reviewed for abuse. This failure resulted in R2 sustaining an injury near the right eye and being sent to the hospital for evaluation. It can be determined that the reasonable person would have experienced psychosocial harm as a result of the physical abuse, since a reasonable person would not expect to be injured in this manner in his/her own home or a health care facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and maintain an effective pest control program. These failures have the potential to affect 174 resident's residing in the facility. Findings Include: On 11/25/2025 at 9:53 AM, surveyor observed R159 laying on his bed free of pain. R159 is alert and oriented to person, place or time. R159 stated he has seen roaches today in the bathroom. Surveyors open the bathroom door and observe one small roach on the ground. R159 stated he has not seen an exterminator from the pest control company come in to spray medication to get rid of the roaches. On 11/25/2025 at 10:04 AM, Surveyor observed R70 sitting on the edge of the bed. R70 appears to be comfortable and free of pain. R70 is alert and oriented to person, place and time. R70 stated he has seen roaches in his bathroom, dresser, and nightstand. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow the Resident Assessment Instrument (RAI) manual to reflect an accurate assessment for one (R109) out of six residents' Minimum Data Set (MDS) assessment reviewed in a total sample of thirty-seven. Findings Include:R109's face sheet shows he is [AGE] years old, admitted to the facility on [DATE] with diagnoses not limited to personal history of transient ischemic attack (TIA) and cerebral infarction, Gastrostomy status, adult failure to thrive, essential hypertension, type 2 diabetes mellitus, developmental disorder of scholastic skills, and unspecified asthma. On 11/25/25 at 1:18 PM, R109 is seated in his wheelchair with limitations to his left hand. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to date/label and maintain proper storage of nebulizer tubing and mask when not in use for one (R3) out of one resident reviewed for respiratory care in a final sample of 37. Findings Include:On 11/25/25 at 10:01 AM, R3's resting comfortably in bed. R3's nebulizer machine was not being used, not inside a clear bag, was sitting on top of R3's nightstand. R3's nebulizer tubing mask was sitting on top of the nebulizer machine and was not inside a clear bag. R3's nebulizer tubing and mask had dates labeled 10/22/25. R3 stated he gets nebulizer treatment as needed for COPD (Chronic Obstructive Pulmonary Disease). On 11/25/25 at 10:10 AM, V6 (Assistant Director of Nursing) stated that nebulizer tubing and mask are changed weekly and as needed. V6 said the tubing and the mask should be dated when it was last changed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide honey thickened liquids as ordered by the physician for one resident (R138) during an activity function in a total sample of 37. Findings Include: On 11/25/25 at 12:30 PM, observed R138 sitting at table next to V23 (Activity Aide). R138 had mechanical soft items on her lunch plate, a closed container of honey thickened milk, an opened container of honey thickened juice and an opened can of soda next to her plate of food. R138's meal ticket read mechanical altered/ground, honey thick milk. On 11/25/25 at 12:32 PM, V23 stated R138 can only drink honey thickened liquids. V23 stated the soda can is in front of R138 because R138 requested it, but R138 is not drinking it. V23 stated the soda is not thickened. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident. This failure affected 1 (R2) resident who vocalized that he felt that his life was in terrible danger when a resident (R5) slapped him on his face.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure kitchen tongs and measurement pitchers were properly cleaned and sanitized and food was removed and discarded from the prep refrigerator by the use by date This failure has the potential to affect all the residents in the facility. Findings Include: On 09/17/24 at 09:34 the surveyor entered the kitchen for the initial tour with V14 (Dietary Manager). Red rice/chicken was observed in the prep refrigerator dated 07/12/24 - 07/16/24. V14 stated the wrong month was written on there but today is 09/17/24. On 09/18/24 at 09:35 AM the surveyor entered the kitchen. The Menu dated Wednesday 09/18/24 consisted of Beef Ravioli, Italian Parmesan, Medley Mixed Vegetables, French Garlic Bread and Pineapple Up-side Down Cake. On 09/18/24 at 09:47 AM V18 (Cook) place Steak burgers in a pan using tongs on top of stove. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure contracted staff wore appropriate Personal Protective Equipment (PPE) while caring for a resident (R34) on Enhance Barrier Precautions (EBP) and failed to ensure proper linen storage/handling. These failures have the potential to affect all 171 residents that reside in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide supervision of residents during a smoking break and demonstrate competency and knowledge related to safety measures and equipment for the smoking patio and failed to secure first and second floor soiled utility rooms that contained sharps and infectious waste containers. These deficient practices have the potential to affect all residents who are identified as smokers (R15, R26, R40, R59, R75, R87, R93, R95, R111, R112, R117, R125, R128, R129, R137, R149, R151, R154, R159, R160, R163, R170, R171) and all ambulatory residents that reside on the first and second floors, in the sample of 35.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide appropriate treatment and services to prevent complications from enteral feeding for 2 (R35, R132) of 6 residents reviewed for enteral feedings. The facility also failed to ensure expired enteral feeding products were removed and unavailable to be administered to residents. This failure has the potential to affect 2 (R29, R36) residents that receive enteral nutritional feedings. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired medications were removed and unavailable to be administered to residents. This failure has the potential to affect all residents receiving medications from the 2 North Front medication cart.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu for residents receiving a pureed diet. This failure has the potential to affect 19 residents receiving a pureed diet. Findings Include: On 09/18/24 at 11:29 AM the kitchen staff began plating from the steam table. Staff was observed plating pureed ravioli, pureed medley mixed vegetable and mash potatoes to be served for the residents that receive a pureed diet. There was no pureed bread served. On 09/19/24 at 03:25 PM V20 (Registered Dietician) stated If it says a pureed bread item on the meal ticket the resident should be receiving it. The residents on the pureed diet should have received ravioli, mixed vegetables, French garlic bread and pineapple upside down cake. The residents could receive mashed potatoes in place of the bread. That would not be following the menu. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to place a hand splint to the left hand for contracture management for 1 (R145) resident reviewed for range of motion in a sample of 35. Findings Include: R145 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Cerebral Infarction due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery, Aphasia Following Cerebral Infarction, Dysphagia Following Cerebral Infarction, Dysarthria Following Cerebral Infarction, Facial Weakness Following Cerebral Infarction, Occlusion and Stenosis of Unspecified Carotid Artery and Essential (Primary) Hypertension. R145's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Order Summary Report dated 09/18/24 document in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to change an intravenous catheter dressing timely for 1 (R33) resident reviewed for intravenous catheter care in a sample of 35. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food items in a residents personal refrigerator was labeled and dated for one resident (R143) reviewed in a total sample of 35 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functioning call light system for one (R14) resident in a total sample of 35 residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to provide services in compliance with applicable federal, state, and local laws, regulations, and codes, and with accepted professional standards and principles by not scheduling service plan meetings for the [NAME] Consent Decree Program in an effort to transition residents back into the community. This failure has the potential to affect 28 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed assert the right of the resident by failing to ensure a resident's personal belongings were inventoried upon readmission to the facility. This failure affects one (R1) resident out of three residents reviewed for resident rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff providing care and services to a resident who has a feeding tube is competent in and utilize facility protocols regarding feeding tube nutrition and care. This failure affects one (R2) resident receiving enteral nutrition feedings out of three residents reviewed.

Inspectors wroteBased on observation, interview, and record review the facility staff failed to document on the individual residents controlled drug administration record for 5 residents (R124, R167, R75, R67 and R159). This failure has the potential to affect all 172 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary shower room and bathroom for residents on the north wing of the first floor. This failure has the potential to affect all 46 residents on the north wing of the first floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of cigarette odor and failed to consider nonsmoking residents on the first floor of the facility. This failure has the potential to affect all 55 non-smoking residents on the first floor.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's lower extremity and incontinence brief were covered for dignity. This failure affected 1 (R142) resident reviewed for dignity in the total sample of 59 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a homelike environment for two residents (R164 and R18) in the sample of 59 residents.

Inspectors wroteBased on observation, interview and record review the facility to provide nail care to two residents (R7, R77) out of a sample size of 59. R7 has a diagnosis of but not limited to Parkinson's Disease without Dyskinesia, Nonexudative Age-Related Macular Degeneration, Type 2 Diabetes Mellitus, and Dysphagia. Brief Interview of Mental Status score is 13 that indicates cognitively intact. R77 has a diagnosis of but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Vascular Dementia, Type 2 Diabetes Mellitus with Hyperglycemia and Cerebral Infarction. R77's Brief Interview of Mental Status score is 13 that indicates cognitively intact.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide foot care/podiatry care for a resident. This failure affects one resident (R92) in a sample of 59 residents, reviewed for foot care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of <5% for 1 (R68) of 4 (R68, R91, R132, and R161) residents reviewed for medication administration. There were 32 opportunities and 4 errors resulting in 12.5% medication administration error rate.

Inspectors wroteBased on observation, interview and record review the facility failed to properly log refrigerator temperatures for two resident's (R91, R16) personal refrigerators. This failure has the potential to affect all 59 residents in the sample. R16 has a diagnosis of but not limited to Cerebral Infarction, Non-Pressure Chronic Ulcer of Right Calf with Fat Layer Exposed, Obesity, Type 2 Diabetes Mellitus, and Hypertension. R16's Brief Interview of Mental Status score is 15 that indicates cognitively intact. R16's admission date is 8/01/2022. R91 has a diagnosis of Atrioventricular Block, Mild Cognitive Impairment, Hypothyroidism, Type 2 Diabetes Mellitus and Psychosis. R91 has a Brief Interview of Mental Status score of 14 that indicates cognitively intact. R91 admission date is 10/08/2020.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who depends on staff's assistance for ADL (Activities of Daily Living) care call device was responded to in a timely manner. This failure affected one resident (R1) out of four residents reviewed for ADL care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident (R1) who depend on staff's assistance for their ADL (Activities of Daily Living) care received showers/bed baths. This failure affected one out of four residents reviewed for ADL care and showers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove a faulty power cord resulting in a series of orange-red sparks accompanied by puffs of smoke and a series popping noises. This deficient practice has the potential to affect one of two residents (R3) reviewed for faulty power cords and could affect all residents in the entire building, as well as an indeterminable number of staff and visitors. The Immediate Jeopardy began on 9.4.2023. V1 (Administrator) was notified on 9.19.2023 at 2:14 PM of the Immediate Jeopardy. The facility presented the removal plan on 9.19.2023 at 3:14 PM. The plan was accepted on 9.20.2023 at 8:29 AM. The surveyor conducted onsite observations, interviews, and record reviews to confirm the removal plan was implemented. V1 (Administrator) was informed on 9.20.2023 that the Immediate Jeopardy was removed. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and complete admission contracts to three of five residents (R1, R3, and R5) upon admission to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that facility staff did not store their personal belongings in a resident's closet for one (R3) of five residents reviewed for homelike environment.