Prince of Peace Care Center

In the surveyor’s words

From the most serious findings on record at Prince of Peace Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 16, 2026

  Based on record review, review of the facility reported incident (FRI), and staff interview, the facility failed to ensure adequate supervision for 1 of 1 closed record (Resident #54) reviewed with a choking incident. Failure to prevent a resident from accessing and ingesting food inconsistent with their diet resulted in a choking incident and death. This citation is considered past non-compliance based on the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on 01/06/26. The facility implemented and completed corrective action on 01/12/26. Review of Resident #54's medical record occurred on April 15-16, 2026. […]

• Actual harm, isolatedF689Dec 22, 2025

  Based on review of the facility reported incident (FRI) investigation and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell from a mechanical lift. Failure to ensure proper connection of the sling safety loops to the lift resulted in a fall with injury to Resident #1 and has the potential for falls/injuries for all residents who utilize a mechanical lift. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident.Findings include: The surveyor determined a deficient practice existed on 12/15/25. […]

• No harm, potential for more than minimal, isolatedF637Apr 16, 2026

  Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, the facility failed to complete a Significant Change in Status Assessment (SCSA) for 1 of 15 sampled residents (Resident #22) who experienced a significant change in status. Failure to determine the need for and complete a SCSA in response to a resident's decline limited the facilities ability to identify and implement appropriate care approaches. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.20.1), dated October 2025, page 2-24 stated, . A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention . 2. […]

• No harm, potential for more than minimal, isolatedF880Apr 16, 2026

  Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 13 sampled residents (Resident #22 and #23) observed during cares. Failure to practice infection control standards related to hand hygiene and glove usage has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 04/15/26. This policy, dated September 2023, stated, . Times to perform Hand Hygiene are, but not limited to: . Before and after direct resident contact . Before and after entering isolation precaution setting . Before and after assisting a resident with personal cares . […]

• No harm, potential for more than minimal, isolatedF759Nov 23, 2022

  Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 1 of 8 residents observed during medication administration (Resident #13). Three medication errors occurred during staff administration of 30 medications, resulting in a 10% error rate. Failure to properly prepare and administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions. Findings include: Review of policy titled Insulin Administration- PEN occurred on 11/22/22. This policy, revised January 2018, stated, . H. remove the cap from the pen and wipe the rubber stopper with an alcohol wipe. I. Attach a needle to the insulin pen following manufacturer's guidelines. J. […]