Pettigrew Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF600May 19, 2022

  Based on record review, staff interviews, family interview, and physician interview, the facility failed to protect a resident's right to be free from employee to resident abuse for 1 of 3 residents (Resident #1) reviewed for abuse. Nurse Aide (NA) #7 mocked and intimidated Resident #1 when she refused his assistance and Resident #1 expressed NA #7 inappropriately touched her breast. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated 1/25/22 revealed a focus area for impaired communication related to [CONDITION(S)]. […]

• No harm, potential for more than minimal, widespreadF812Mar 7, 2025

  Based on observations and staff interviews, the facility failed to: 1) Maintain the chemical sanitizing solution of the dish machine at the correct concentration according to the manufacturer's recommendations; 2) Change gloves/wash hands between handling soiled and clean dishes to prevent cross-contamination of the clean dishes and failed to allow all clean dishware to air dry; 3) Dispose of expired food items and seal, label, and/or date opened food items observed in food storage areas; 4) Cover facial hair for 4 of 4 Dietary staff observed with facial hair and working in food preparation (Cook #1, [NAME] #2, Dietary Aide #1 and Dietary Aide #2); and 5) Keep the kitchen food service equipment and vents clean within the Dietary Department. […]

• No harm, potential for more than minimal, widespreadF812Feb 9, 2023

  Based on observations, staff interviews and an interview with the service technician for the facility's dish machine, the facility failed to: 1) Maintain the chemical sanitizing solution of the dish machine at the correct concentration according to the manufacturer's recommendations during 1 of 1 observations of the dish washing process; 2) Failed to change gloves/wash hands between handling soiled and clean dishes to prevent cross-contamination of the clean dishes and failed to allow all clean dishware to air dry during 1 of 1 observations of the dish washing practices; and 3) Dispose of expired food items and seal, label, and/or date opened food items observed in food storage areas during 2 of 2 observations of the facility's food storage areas. The findings included: 1. […]

• No harm, potential for more than minimal, widespreadF812Oct 28, 2021

  Based on observations, staff interviews and record review the facility failed to label leftovers and discard expired food from their walk- in refrigerator and failed to maintain the walk-in freezer in a safe operating condition. The kitchen's walk-in freezer had accumulated ice on the freezer floor. The facility failed to ensure the commercial dishwasher was maintaining wash and rinse temperatures according to the manufacturer's recommendations, failed to use clean lids to cover food on the steam table, failed to ensure the glasses and cups stacked on the drying rack were clean and failed to ensure the sanitization solution strength used on the kitchen counter tops was within manufacturer's recommendation. […]

• No harm, potential for more than minimal, patternF761Mar 7, 2025

  Based on observations and staff interviews, manufacturer's literature review, the facility failed to date opened multi-dose vials of insulin medication in 2 of 5 medication administration carts (Long and Short halls), failed to discard expired insulin pens in 1 of 5 medication administration carts (Short hall) and discard loose pills in the medication cart drawers for 3 of 5 medication administration carts (Rehabilitation, Long and Short halls). Findings Included: a. On 3/3/25 at 10:00 AM, an observation of the medication administration cart of Rehabilitation Hall with Nurse #6 revealed in the second drawer of the medication cart, which contained over-the-counter medications, there were noted three white loose pills and two yellow round-shaped loose pills and one blue oval shape loose… […]