Petersburg Healthcare Center

In the surveyor’s words

From the most serious findings on record at Petersburg Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Mar 13, 2026

  Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to protect the resident's right to be free from abuse and neglect for four residents in a survey sample of 53 residents (Resident #61- R61, Resident #74-R74, Resident #76-R76, and Resident #77-R77). This non-compliance resulted in R61 sustaining a fracture, R74 having a bloody nose, R76 having scratches, all which required medical interventions, which constituted harm for those three of the four residents. This noncompliance resulted in the identification of immediate jeopardy (IJ) and substandard quality of care which began on 10/29/24 and required immediate facility intervention to protect residents from abuse and neglect. […]

• Actual harm, isolatedF660Apr 15, 2022

  Based on observations, resident and staff interviews, and medical record and facility policy reviews the facility failed to provide Resident (R51) with essential discharge planning. This failure impacted R51's psychosocial wellbeing, causing him anxiety at times and desperation to return to his community. This is harm. The facility failed to meet this requirement by failing to: 1. Ensure R51's discharge goals were clearly understood through the use of an interpreter. 2. Develop a discharge plan for R51 to return to his community. 3. Regularly evaluate R51 for his desire to return to his community and assist with resources to make his transition successful. Findings include: Observation on [DATE] at 11:00 AM, revealed R51 at the Receptionist's window. […]

• No harm, potential for more than minimal, widespreadF880Apr 15, 2022

  Based on staff interview and facility documentation review, the facility staff failed to develop and implement a water management plan for Legionella with regards to a risk assessment to identify where Legionella and other waterborne bacteria could grow, which has the ability to affect all Residents residing at the facility. The findings included: On 4/14/22, during review of the facility water management program the facility submitted an incomplete and inaccurate facility risk assessment, used to identify where Legionella and other waterborne bacteria could grow and spread in the facility water system. This was reviewed with the facility Administrator and Director of Maintenance, who confirmed the form was not accurate and incomplete. […]

• No harm, potential for more than minimal, widespreadF803Mar 25, 2021

  Based on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to follow the planned menu for 19 prepared meal trays in a survey sample of 19 prepared meals. The findings include: For the lunch meal service provided to residents, the facility staff failed to provide a pear crisp as indicated on the facility's planned menu for 3-24-21. On 3-24-21 at approximately 11:45 pm during meal tray preparation in the kitchen, Surveyor A observed pre-packaged diced pears in single serving cups on the residents' lunch meal trays. The meal tickets on the trays indicated pear crisp. At approximately 4:40 pm, Surveyor A conducted an interview with the Dietary Manager (Employee C) and was asked to describe pear crisp. […]

• No harm, potential for more than minimal, patternF677Mar 13, 2026

  Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 resident (#29) in a survey sample of 53 residents.For resident #29 (R29) the facility staff failed to ensure adequate hygiene and grooming assistance for a resident who is dependent on staff for ADL careR29 was admitted to the facility on [DATE] with diagnosis and that included but not limited to atrial fibrillation, alcohol, abuse, history of right hemispheric CVA with left upper extremity weakness, low back pain, and alcohol induced dementia. […]