Peterson Rehabilitation and Healthcare

In the surveyor’s words

From the most serious findings on record at Peterson Rehabilitation and Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 28, 2024

  Based on record review and staff interview, the facility failed to protect Resident #39's right to be free from sexual abuse. This was true for one (1) out of five (5) resident-to-resident altercations reviewed during the complaint process. Facility census: 135. Resident identifiers: #39 and #137. The facility's failure to follow their abuse policy and recognize the incident as an occurrence of resident-to-resident sexual abuse placed an unlimited number of residents currently residing in the facility at risk for possible abuse. The state agency determined this was an immediate jeopardy (IJ) situation. […]

• Immediate jeopardy, isolatedF605May 28, 2024

  Based on record review and interview the facility failed to keep Resident #38 free from a chemical restraint imposed for purposes of discipline when an antipsychotic medication was given without a physician order. The deficient practice put all one (1) resident that exhibit behaviors currently residing in the facility at risk for serious injury, serious harm, serious impairment, or death. Resident identifier: #38. Facility Census: 135. Findings included: a) Resident #38 During a complaint survey a review of Resident #38's nursing progress notes found: Nursing note dated 05/5/24 4:35 AM Came onto wing at 2:20, patient (pt) came out screaming and chasing the staff down the hallway because they wanted a regular diet, was told to go back to their room, patient went into the room and laid… […]

• Immediate jeopardy, isolatedF689May 28, 2024

  Based on observation and staff interview the facility failed to ensure the residents environment over which it had control was free from accident hazards related to Resident # 27 received a burn after spilling reheated hot coffee on herself. The deficient practice put all residents that drink coffee currently residing in the facility at risk for serious injury, serious harm, serious impairment, or death. Resident identifiers: #27. Facility census: 135. Findings included: a) Hot Liquids Review of facility documentation during a Facility reported Incident investigation (FRI) showed a reportable dated 10/30/23. The incident occurred on 10/30/23 when Resident # 27 sustained a burn injury to the right side of her abdomen after spilling coffee on herself that had been reheated. […]

• Actual harm, isolatedF656May 28, 2024

  Based on record review, and staff interview, the facility failed to ensure one (1) of three (3) residents had a person-centered comprehensive care plan implemented to meet his/her other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Failure to implement Resident #72's care plan resulted in her sustaining a burn to her abdomen which required physician intervention. Resident #72 sustained actual harm due to the facility's failure to implement her care plan. Resident identifiers: #27. Facility census: 135. Findings included: a) Resident #27 Review of facility documentation during a Facility Reported Incident (FRI) investigation showed a reportable dated 10/30/23. […]

• No harm, potential for more than minimal, widespreadF725Aug 23, 2023

  Based on facility record review, medical record review and staff interview, the facility failed to ensure there is sufficient qualified staff available at all times to meet the needs of the residents. The nursing supervisor failed to deploy staff in a manner to ensure all residents were assigned a care giver. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #73 and #48. Facility census: 132. Findings included: a) Staff Postings The staff posting dated 07/29/23 lists two (2) Registered Nurses (RN), two (2) Licensed Practical Nurses (LPNs) and six (6) Nurse Aides (NAs) for the 11:00 PM to 7:00 AM shift to care for 135 residents on seven (7) halls. […]