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

The facility failed to obtain ordered laboratory tests (CBC and BMP) for one resident, resulting in actual harm that required hospital ICU admission. The ordered labs were not collected despite multiple attempts, and the failure to obtain labs contributed to delayed treatment and transfer.

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 unmet care needs. The medication order for Meropenem was not entered or activated in the medical record, resulting in Resident 1 receiving the wrong antibiotic.

The complaint investigation focused on a fall incident involving Resident 1. The investigation found that the fall was not properly witnessed as initially reported, and staff left the resident unattended during smoking assistance. The allegation was substantiated with discrepancies noted in the facility's fall investigation.

The facility failed to properly investigate a fall for one resident, resulting in discrepancies between the fall investigation report and interviews with staff and the resident. The fall was incorrectly documented as witnessed when the resident was left unattended, placing residents at risk of unmet care needs.

The complaint investigation focused on failure to obtain and document vital signs for Resident 1 upon admission and before administration of Metoprolol. Interviews with multiple nursing staff confirmed the vital signs were not documented in the electronic medical record. The allegation was substantiated with citations.

The facility failed to ensure vital signs were obtained and documented upon admission and prior to administering blood pressure medication for one of four sampled residents. Interviews with nursing staff confirmed the absence of vital signs documentation in the resident's electronic medical record, placing residents at risk of unmet care needs.

The facility failed to comply with regulations by allowing two nurse technicians with expired credentials to administer scheduled and intravenous medications, placing residents at risk of medication errors and harm. The findings document unauthorized medication administration by these staff members.

The complaint was that the dietary manager lacked dietary management certification. Interviews confirmed the Dietary Manager was uncertified but was in the process of obtaining certification and awaiting a proctor for the final test.

The facility failed to ensure the Dietary Manager had the required certification to perform their duties, placing residents at risk of receiving menus prepared by unqualified staff. The Dietary Manager was in the process of obtaining certification but had not yet completed it.

The facility was found to have multiple deficiencies including failure to maintain advance directives, incomplete assessments and consents for physical restraints, inadequate coordination of PASARR evaluations, lack of person-centered care plans and activities, inaccurate enteral nutrition pump settings, missed medication documentation, inadequate assistance with activities of daily living, failure to initiate bowel protocols, incomplete respiratory care documentation, improper medication storage, failure to disinfect shared medical equipment, and unsafe bed rails. All deficiencies were cited with minimal harm and affected few residents.

The facility failed to update the care plan for one of three sampled residents after a change in condition related to a penile lesion. The deficiency was cited with minimal harm potential and affected a few residents.

The complaint involved Resident 1 who was not readmitted after leg amputation surgery. Staff interviews revealed the facility denied readmission due to insurance changes and concerns about drugs found in the resident's belongings. The facility did not provide a discharge plan or written explanation to the resident. The complaint was substantiated with citations.

The facility failed to ensure that Resident 1 was readmitted after hospitalization, placing residents at risk for increased anxiety and diminished quality of life. The resident's discharge plan was not addressed, and the facility cited insurance issues and concerns about substances in the resident's belongings as reasons for non-admission.

The complaint investigation focused on Resident 1's fall on 12/31/2024. The facility substantiated that the nurse on duty did not assess the resident after the fall despite being informed. Resident 1 and witnesses reported the nurse failed to respond appropriately. The facility set expectations for nurses to investigate falls and initiate interventions promptly.

The facility failed to ensure Resident 1 was assessed immediately after a fall on 12/31/2024, resulting in delayed neurological checks and assessment. The investigation substantiated that the nurse on duty did not perform due diligence to assess the resident after the fall was reported.

The facility was found to have deficiencies in food storage cleanliness, juice dispensing area sanitation, and kitchen floor maintenance. Management acknowledged the issues and had plans to address them promptly.

The facility was found deficient in multiple areas including failure to obtain consent, evaluation, and physician orders for physical restraints; failure to develop comprehensive care plans for residents using restraints; inadequate restorative services for residents; failure to maintain cleanliness and proper labeling in food storage areas; and failure to provide follow-up education for pneumococcal vaccination. All deficiencies were cited with minimal harm potential and affected few to many residents.

The complaint investigation focused on Resident 1's narcotic overdose incident. The allegation that the facility did not conduct a proper investigation was substantiated based on record review and staff interviews.

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, placing residents at risk of medication errors and decreased quality of life.

The facility was found to have multiple deficiencies including failure to respect resident dignity, incomplete consent and notification processes, inadequate care planning for medications and diagnoses, poor odor control, failure to monitor anticoagulant side effects, improper respiratory care orders, and food service issues including cold and unpalatable meals. Several deficiencies were noted as minimal harm with some residents affected. No overall approval status was stated.