Peterson Park Health Care CTR

In the surveyor’s words

From the most serious findings on record at Peterson Park Health Care CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 22, 2023

  Based 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. […]

• Actual harm, isolatedF600Jan 30, 2026

  Based 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. […]

• Actual harm, isolatedF600Mar 21, 2023

  Based upon observation, interview and record review the facility failed to follow the abuse/neglect policy and failed to ensure that two of four residents (R3, R4) reviewed for abuse remained free from abuse. These failures have the potential to affect 45 (2 South) residents. On (2/21/23) R3 pushed R2 into R4 causing both residents (R2, R4) to fall, R4 sustained dizziness and head/neck/right shoulder pain rated 3 out of 10. Findings include: The (3/14/23) census includes 45 (2 South) residents. The (2 South) memory care unit is locked to prevent elopement. R3's diagnoses include dementia with agitation and other conduct disorders. R3's (12/28/23) BIMS (Brief Interview Mental Status) affirms resident was unable to complete the interview. […]

• Actual harm, isolatedF689Jan 26, 2023

  Based upon interview and record review, the facility failed to implement the fall prevention interventions plan of care according to resident's assessment. This failure affected one resident(R2) of three residents reviewed for falls. As a result, R2 fell from the bed to the floor and sustained a blunt force injury to the neck. R2 was later pronounced dead after the paramedics arrived at the scene of the accident. Findings include: On [DATE] during this investigation, V2(Director of Nursing) presented the facility's incident investigation of R2's fall event and the Police Report Case number, with the written statement from V13(Agency CNA/Certified Nurse Assistant). […]

• No harm, potential for more than minimal, widespreadF925Nov 29, 2025

  Based 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. […]