PA Peterson at the Citadel

In the surveyor’s words

From the most serious findings on record at PA Peterson at the Citadel, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jun 30, 2022

  Based on interview and record review the facility failed to ensure R2 and R3 were free from sexual abuse by R1 and failed to have interventions in place for R1 who had known sexual behaviors. The facility also failed to ensure R4 was free from physical abuse by R1. This applies to 4 of 5 residents (R1, R2, R3, and R4) reviewed for abuse in the sample of 5. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on June 16, 2022, when R1 masturbated in front of R3. The Immediate Jeopardy was identified on June 27, 2022. V1 Administrator was notified of the Immediate Jeopardy on June 29, 2022. […]

• Immediate jeopardy, isolatedF689Jun 13, 2023

  Based on observation, interview, and record review the facility failed to safely feed a resident with difficulty swallowing and failed to ensure a resident's mouth was clear of food. This applies to one of eight residents (R70) reviewed for safety in the sample of 23. These failures resulted in R70 being found expired after being found in the dining room with food in his mouth. The Immediate Jeopardy began on [DATE] when R70 was first observed not swallowing his food while staff continued to spoon food in his mouth. R70 was left with food in his mouth. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 2:45 PM. […]

• Immediate jeopardy, isolatedF760Dec 2, 2021

  Based on interview and record review the facility failed to ensure a resident (R1) was properly identified prior to administering medication to prevent a significant medication error. This failure contributed to R1 developing [CONDITION(S)] requiring emergency medical intervention and hospitalization . This applies to 1 of 3 residents (R1) reviewed for medication errors in the sample of 7. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/26/2021, when the facility failed to administer prescribed opiate medication ([MEDICATION(S)]) to the right resident. R1 was given another residents medication on the morning of 11/26/2021. […]

• Actual harm, isolatedF684Jul 10, 2024

  Based on observation, interview, and record review the facility failed to assess and monitor a resident's(R94) ankle. This failure resulted in R94 developing an infected ankle that caused a post-surgical screw to protrude out of her ankle and be admitted to the local hospital for surgical cleaning and repair. The facility failed to identify, assess and implement treatment interventions for a resident(R24) with new wounds. This applies to 2 of 25 residents (R24 and R94) reviewed for quality of care in the sample of 25. The findings include: 1. R94's Minimum Data Set assessment dated [DATE] shows that her cognition is intact. On 7/8/24 at 9:27 AM, R94 was self propelling down the hallway in her wheelchair. R94's right lower leg was swollen. There was a gauze wrap around her ankle. […]

• Actual harm, isolatedF686Jul 10, 2024

  Based on observation, interview, and record review the facility to report new pressure injuries. The facility failed to ensure pressure injury prevention interventions were in place. The facility failed to identify a resident's pressure injury prior to the injury becoming a Stage III injury. These failures resulted in R101 developing a Stage III pressure injury to her coccyx and Stage II pressure injuries to each of her buttocks. The facility failed to ensure pressure treatment interventions were in place and failed to complete weekly assessments on residents(R82, R24) with pressure injuries. This applies to 3 of 11 residents (R101, R82, R24) reviewed for pressure injuries in the sample of 25. The findings include: 1. […]