Inspection Reports for
Central Guest House Healthcare & Rehabilitation Ce

The facility was found deficient in multiple areas including failure to complete Significant Change MDS assessments timely for hospice residents, inaccurate coding of MDS assessments, failure to post nurse staffing data in a prominent place, improper labeling and storage of medications, failure to use beard restraints in food preparation, and failure to implement proper infection control PPE protocols during high-contact care.

The complaint involved an allegation of verbal abuse by staff member S8CNA towards Resident #8, which was not reported to the administrator or state survey agency within 2 hours as required. The allegation was substantiated by interviews with Resident #8, nurse S9LPN, and administrator S1ADM.

The facility failed to report an alleged verbal abuse incident involving Resident #8 within the required 2-hour timeframe and failed to complete and transmit MDS assessments timely for Resident #1. Interviews and record reviews confirmed these deficiencies.

The facility failed to initiate and resolve grievances for one resident, failed to provide necessary nail care for two residents requiring assistance with ADLs, and failed to properly label oxygen tubing and humidification bottles for two residents receiving oxygen therapy. These deficiencies were identified through record reviews, observations, and interviews.

The complaint investigation revealed substantiated deficiencies including failure to resolve grievances, incomplete assessments, inadequate ADL care, failure to obtain and clarify physician orders upon hospital readmission leading to immediate jeopardy, improper respiratory care labeling, medication labeling issues, and unsafe food storage practices.

The facility failed to initiate and resolve grievances for a resident, complete timely quarterly assessments, provide necessary ADL care including nail trimming, ensure proper physician orders upon hospital readmission, maintain safe respiratory care with proper labeling, ensure insulin pens were labeled and discarded appropriately, and store food in accordance with safety standards.

The complaint investigation focused on an incident on 11/05/2023 where Resident #3 yelled, cursed, and shoved Resident #R2. Interviews with residents and staff confirmed the incident as verbal and physical abuse. The facility staff did not report the incident to the state survey agency within the required timeframe. The facility administration initially did not consider the incident abuse due to the relationship between the residents (husband and wife).

The facility failed to ensure a resident's right to be free from physical and verbal abuse by another resident. Additionally, the facility failed to timely report the alleged abuse to the state survey agency. The investigation also found medication administration issues, including failure to provide ordered medication (Ambien) and inaccurate documentation of medication administration.

The complaint involved Resident #3 being left unsupervised in the whirlpool tub on 10/25/2023, leading to rising water and soap suds that caused the resident to feel nervous and afraid. The complaint was substantiated by multiple staff interviews confirming the incident.

The facility failed to ensure adequate supervision of Resident #3 during a whirlpool bath, resulting in the resident being left alone in the tub with rising water and soap suds. Multiple staff interviews confirmed the resident was left unsupervised, which is against facility policy and unsafe.

No health deficiencies were found during the inspection.

The complaint investigation was triggered by an Immediate Jeopardy situation when CPR was stopped on Resident #143 due to conflicting advance directives indicating both DNR and full code status. Further review revealed discrepancies in code status documentation for Residents #81, #112, and #136, and staff confusion about which orders to follow in emergencies.

The facility failed to ensure an effective system was in place for advanced directives, resulting in conflicting code status orders for several residents, including Resident #143, who had CPR stopped prematurely due to unclear directives. Discrepancies were found in the medical records of multiple residents, and staff were unaware of the correct code status to follow in emergencies. The facility implemented a plan of removal and corrective actions including staff in-service training, audits, and policy reviews.