Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Petersburg Medical Center Ltc during CMS and state inspections, most recent first.
Staff failed to follow infection control procedures when a CNA provided perineal care to a resident with peripheral vascular disease, stroke, and hemiplegia/hemiparesis. After cleansing the resident’s buttocks and anal area while wearing gloves, the CNA did not change gloves or perform hand hygiene before pulling up the resident’s swim trunks, moving directly from a dirty task to a clean task. Facility leadership and the ICP confirmed that staff are expected to perform hand hygiene and change gloves between contaminated and clean tasks, consistent with the facility’s hand hygiene policy.
The facility did not post complete daily nurse staffing information as required. Observations showed that a hallway whiteboard listed the date, first names of nursing staff and CNAs on duty, general shift times, and the resident census, but did not include the total number of CNAs, LPNs, and RNs per shift or the actual hours worked by each staff type. The CNO acknowledged that nurse staffing hours were not posted and that only a non-public file at the nurse’s desk contained historical staff schedules, with no notice to residents or visitors about its existence, resulting in inaccurate staffing information being available to residents and families.
The facility failed to submit mandatory PBJ data for FY Quarter 4 2023, resulting in a one-star staffing rating. The Interim Administrator acknowledged the missed submission during an interview.
The facility failed to attempt gradual dose reductions (GDRs) on psychotropic medications for three residents, placing them at risk for unnecessary medications. Despite the facility's policy requiring GDR attempts, no such attempts or contraindications were documented for these residents.
The facility failed to provide a Minced and Moist (MM5) diet as ordered for a resident and did not offer an alternative of MM5 texture when needed. The resident, with multiple diagnoses including dysphagia and poor dentition, received pureed food instead of the specified MM5 texture, leading to emotional distress and refusal to eat. Staff interviews and policy reviews revealed a lack of adherence to dietary specifications and failure to provide appropriate alternatives.
A facility failed to ensure proper hand hygiene during wound care for a resident with erythema and an ingrown toenail. An LN applied Bacitracin ointment without changing gloves or cleaning the site, leading to potential infection risk.
Failure to Perform Hand Hygiene and Glove Change Between Dirty and Clean Tasks
Penalty
Summary
The deficiency involves a failure to follow infection control procedures during personal care for one resident. Record review showed the resident had peripheral vascular disease, a history of stroke, and hemiplegia/hemiparesis. During an observation, the resident was standing at the bedside after using a bedside commode, with swim trunks around the lower legs and a gait belt secured at the waist for stability. One CNA stood in front of the resident holding the gait belt to assist with stability, while another CNA, who was wearing gloves, performed perineal care. The gloved CNA cleansed the resident’s buttocks and anal area with a wet washcloth and then used a dry washcloth to pat the area dry. After completing this contaminated task, the CNA did not change gloves or perform hand hygiene before proceeding to pull up the resident’s swim trunks, which constituted a clean task. In an interview, the CNO and ICP stated that staff were expected to perform hand hygiene and change gloves when moving from a dirty task to a clean task, and that the CNA should have changed gloves prior to touching the resident’s clothing. The facility’s hand hygiene policy required hand hygiene before moving from a contaminated body site to a clean body site during resident care.
Failure to Post Required Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post required daily nurse staffing information, including the total number of CNAs, LPNs, and RNs and the actual hours worked for resident care per shift. During observations over several days, surveyors noted a whiteboard in the LTC unit hallway labeled with the facility name that listed the date, first names of nursing staff and CNAs on duty, general shift times, and the resident census. However, the board did not include the total number of licensed nurses or CNAs per shift, nor did it display the total actual hours worked by each staff type. In an interview, the CNO confirmed that the facility did not post nurse staffing hours, explaining that the whiteboard was updated daily only for the current shift and that historical staff schedules were kept in a file at the nurse’s desk, which was not publicly posted and had no reference directing residents or visitors to its existence. This failure to post complete and accurate nurse staffing information resulted in residents and their families receiving inaccurate information about staffing levels.
Failure to Submit PBJ Data for FY Quarter 4 2023
Penalty
Summary
The facility failed to ensure the mandatory submission of staffing information based on payroll-based journal (PBJ) data for Fiscal Year (FY) Quarter 4 2023 (July 1 - September 30, 2023). This failure was identified during a review conducted from March 4-8, 2024, and on March 11, 2024, which revealed that the facility did not submit the required data for the specified quarter. As a result, the facility received a one-star staffing rating. During an interview on March 7, 2024, the Interim Administrator acknowledged that the PBJ data submission for FY Quarter 4 2023 was missed.
Failure to Attempt Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to attempt gradual dose reductions (GDRs) on psychotropic medications for three residents, which had the potential to place them at risk for unnecessary medications. Resident #5 was admitted with depression and was taking Citalopram 20mg daily since 5/3/22. There was no documentation of a GDR attempt or contraindication for GDR in the medical record. The care plan identified the use of Citalopram but did not document any GDR attempts or contraindications in the physician notes dated 12/27/23 and 2/20/24. Resident #7, admitted with aggression in dementia and depression, was taking Divalproex, Clonazepam, and Citalopram. While GDR attempts were made for Citalopram and Clonazepam, no GDR attempt was documented for Divalproex, nor was there any contraindication noted. The care plan listed the medications but did not document any GDR attempts or contraindications. Similarly, Resident #10, admitted with dementia and aggressive behavior, was taking Divalproex, Olanzapine, and Escitalopram. There were no documented GDR attempts or contraindications for any of these medications in the medical record. During an interview, the physician confirmed that no GDRs were attempted for these medications and was unaware of any contraindications documented in the medical records. The facility's policy on unnecessary drugs required GDR attempts for psychotropic medications within the first year and annually thereafter unless clinically contraindicated. However, the facility did not adhere to this policy for the three residents in question.
Failure to Provide Ordered Diet and Alternatives
Penalty
Summary
The facility failed to ensure that a Minced and Moist (MM5) diet was provided as ordered for one resident, and an alternative of MM5 texture was not offered when needed. Resident #12, who had diagnoses including malnourishment, weakness, dysphagia, cerebral palsy, and poor dentition, was observed multiple times receiving food that appeared pureed instead of minced and moist. This discrepancy was noted during lunch, dinner, and breakfast observations, where the resident's meals did not meet the specified MM5 texture, leading to emotional distress and refusal to eat by the resident. Interviews with staff, including a Certified Nursing Assistant (CNA) and the Dietary Manager (DM), revealed a lack of adherence to the MM5 diet specifications. The CNA acknowledged that the breakfast provided looked pureed rather than minced and moist. The DM explained the facility's process for preparing MM5 diets but admitted that certain foods, like bread, were pureed instead of minced and moist. The DM also noted that alternatives for foods that could not be minced were not provided, and the resident's emotional reactions to the pureed food were known but not addressed adequately. The facility's policies on dietary services and menu substitutions were reviewed, indicating that food should be prepared and served in a form designed to meet individual needs and that substitutes of similar nutritive value should be offered. However, the DM confirmed that alternatives were not provided for the MM5 diet, and the resident's dissatisfaction with the pureed food was documented in Resident Council meeting minutes and a dietary note to the resident's physician. Despite the resident's emotional distress and expressed dislike for the pureed food, the facility did not make necessary adjustments to meet the resident's dietary needs and preferences.
Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during wound care treatment for a resident diagnosed with erythema and an ingrown toenail. During an observation, a Licensed Nurse (LN) was seen removing an adhesive bandage from the resident's right toe while wearing gloves, palpating the toe and exposed wound, and then applying fresh Bacitracin ointment without changing gloves or cleaning the site. The LN placed the Bacitracin directly on the contaminated glove and applied it to the wound, only performing hand hygiene after removing the gloves post-application. The facility's infection preventionist confirmed that the proper practice would have included changing gloves and performing hand hygiene before applying the Bacitracin to avoid contamination. The facility's policy and resource instructions also emphasized the importance of hand hygiene and changing gloves when soiled. However, these protocols were not followed during the observed wound care treatment, leading to a potential risk for infection and compromised wound healing for the resident.
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wrangell Medical Center Ltc | 33.2 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.