Inspection Reports for Prestige Post-Acute and Rehab Center – Centralia

The inspection was conducted to evaluate compliance with regulatory requirements related to laboratory services and diagnostic testing for residents, specifically focusing on the facility's failure to obtain ordered laboratory tests for a sampled resident.

The facility failed to obtain ordered CBC and BMP laboratory tests for one sampled resident, resulting in actual harm. The resident required hospital transfer and ICU admission due to profound anemia, hyponatremia, acute renal failure, and sepsis. Documentation showed unsuccessful attempts to obtain labs and lack of communication with the physician regarding the missed labs.

The inspection was conducted to assess compliance with pharmaceutical services requirements, specifically to ensure that medications ordered by providers were properly administered to residents.

The facility failed to ensure that medications ordered by a provider were administered for 1 of 5 sampled residents, placing residents at risk of delayed healing and diminished quality of life. The deficiency involved a missed antibiotic order for Resident 1, resulting from a communication error during admission medication order entry.

The inspection was conducted to investigate a complaint regarding the facility's failure to thoroughly investigate a fall involving Resident 1, which raised concerns about unmet care needs and diminished quality of life.

The facility failed to properly investigate a fall for Resident 1, who was left unattended by staff during smoking assistance, resulting in a fall from a wheelchair and head injury. Discrepancies were found between the facility's fall investigation and interviews with staff and the resident, indicating the fall was not witnessed as initially documented.

The complaint investigation found that Resident 1 was left unattended by a Nursing Assistant Certified (NAC) during smoking assistance, resulting in a fall. The facility's fall investigation incorrectly documented the fall as witnessed, despite interviews indicating otherwise.

The inspection was conducted as an annual survey to assess compliance with care standards, specifically focusing on vital signs monitoring upon admission and before administration of blood pressure medication.

The facility failed to ensure vital signs were obtained and documented upon admission and prior to administration of blood pressure medication for one of four sampled residents, placing residents at risk of unmet care needs and diminished quality of life.

The inspection was conducted due to concerns that nurse technicians were administering scheduled and intravenous medications, which may be outside their authorized scope of practice.

The facility failed to comply with state and local laws by allowing two nurse technicians with expired credentials to administer scheduled opioid and IV medications, placing residents at risk of medication errors and harm. Interviews confirmed that nurse technicians administered controlled medications without proper education or authorization.

The investigation was complaint-related, focusing on unauthorized medication administration by nurse technicians. The complaint was substantiated based on observations, interviews, and record reviews.

The inspection was conducted to evaluate the qualifications and certification status of the Dietary Manager at the facility.

The facility failed to ensure that the Dietary Manager had the required qualifications and certification to perform their duties, placing residents at risk of receiving menus prepared by unqualified staff.

The inspection was conducted to assess compliance with regulatory requirements related to resident rights, physical restraints, PASARR coordination, care planning, professional standards of practice, activities of daily living, medication administration, infection control, and safety of bed rails.

The facility was found deficient in multiple areas including failure to maintain advance directives, inadequate assessment and documentation for physical restraints, failure to coordinate PASARR Level II evaluations, lack of person-centered care plans for activities, inaccurate enteral nutrition pump settings and medication documentation, failure to provide shaving assistance, failure to initiate bowel interventions, failure to provide continuous oxygen as ordered, improper medication storage, failure to disinfect shared medical equipment, and unsafe bed rails.

The inspection was conducted due to a complaint investigation regarding the facility's failure to update resident care plans after a change in condition.

The facility failed to ensure that resident care plans were updated following a change in condition for one of three sampled residents, placing residents at risk for unmet care needs and decreased quality of life. Specifically, a penile lesion identified on Resident 1 was not incorporated into the care plan as expected.

The complaint investigation found that the facility did not update the care plan for Resident 1 after a penile lesion was identified on 01/31/2025. Staff acknowledged the expectation to update care plans with any change in condition but could not locate a care plan update related to the lesion.

The inspection was conducted due to a complaint regarding the facility's failure to permit a resident to return after hospitalization or therapeutic leave, specifically concerning Resident 1 who was not readmitted following leg amputation surgery.

The facility failed to ensure Resident 1 was readmitted after hospitalization, violating the bed-hold policy. Staff interviews revealed denial of readmission was related to insurance issues and concerns about substances found in the resident's belongings, and no discharge plan was implemented.

The complaint investigation found that Resident 1 was denied readmission after leg amputation surgery due to insurance not being accepted following a change in facility ownership and concerns about drugs in the resident's belongings. Staff were unsure if Resident 1 received written explanation or appeal rights information. No discharge plan was in place.

The inspection was conducted due to a complaint investigation regarding the facility's failure to assess a resident after an unwitnessed fall on 12/31/2024.

The facility failed to ensure Resident 1 was assessed immediately after a fall on 12/31/2024, resulting in delayed neurological evaluations and potential risk of undiagnosed injuries. Staff interviews and resident statements confirmed the nurse on duty did not perform a timely assessment despite being informed of the fall.

The complaint investigation substantiated that the nurse on duty during the 12/31/2024 fall did not assess Resident 1 as required. Resident 1 did not recall the fall but had visible bruising and neurological checks were initiated only the following day. Staff statements conflicted on awareness of the fall, and the facility concluded the nurse failed to do due diligence.

The inspection was conducted based on complaints and observations related to physical restraints, care planning, restorative services, food safety, and immunization follow-up at South Creek Post Acute.

The facility failed to obtain proper consent, evaluation, and physician orders for physical restraints; did not develop comprehensive care plans for residents using restraints; failed to provide consistent restorative services; did not maintain cleanliness and proper labeling in food storage areas; and failed to provide follow-up education for pneumococcal vaccination for a resident.

The visit was complaint-related, focusing on issues with physical restraints, care planning, restorative services, food safety, and immunization follow-up. Substantiation status is not explicitly stated.

The inspection was conducted to investigate a complaint regarding the facility's failure to initiate a facility investigation after a resident was sent to the emergency room and later admitted with a diagnosis of narcotic overdose.

The facility failed to initiate a formal investigation into Resident 1's medication overdose despite evidence of the overdose and hospital admission. Staff interviews confirmed no formal investigation was conducted, and the medication review did not suggest an overdose, but the lack of investigation was noted as a deficiency.

The visit was complaint-related, focusing on the failure to investigate a narcotic overdose incident involving Resident 1. Staff interviews indicated no formal investigation was initiated, and the allegation of an opiate overdose should have been investigated.

The inspection was conducted to assess compliance with regulatory requirements related to resident rights, informed consent, care planning, medication management, food service, respiratory care, and other aspects of facility operations.

The facility was found deficient in multiple areas including failure to respect residents' privacy, obtain informed consent for psychotropic medications, provide advance written notice for room changes, maintain a homelike environment free from odors, complete accurate PASARR assessments, develop comprehensive care plans, provide adequate activities of daily living care, implement physician orders for respiratory treatments, monitor anticoagulant medication side effects, ensure psychotropic medications were necessary and monitored, and maintain food service quality and safety including proper food temperatures.

complaint-inspection_2025-01-07.pdf