Inspection Reports for
The Center at Centennial

The complaint investigation found that the facility did not follow the McGeer Criteria when obtaining urinalysis and treating suspected urinary tract infections, leading to inappropriate antibiotic use. Resident #31 was prescribed three different antibiotics without meeting criteria, and Resident #25 was prescribed an ineffective antibiotic before sensitivity results were available. The complaint was substantiated based on record reviews and staff interviews.

The facility failed to implement an effective antibiotic stewardship program, resulting in inappropriate antibiotic use for residents #25 and #31. The facility did not consistently follow the McGeer Criteria for diagnosing and treating urinary tract infections, leading to residents being prescribed ineffective or multiple antibiotics without proper clinical justification.

The facility failed to implement an effective antibiotic stewardship program, resulting in inappropriate antibiotic use for two residents. The facility did not ensure clinical signs and symptoms of infection were identified or culture results obtained prior to antibiotic administration, leading to multiple antibiotic prescriptions and ineffective treatments.

The complaint investigation found substantiated medication errors for Residents #2 and #3 due to late administration of prescribed medications. Resident #1 sustained an actual harm fall during a hoyer lift transfer due to slipping through the sling. The facility failed to identify root causes or provide adequate staff re-education after the fall.

The facility failed to ensure timely administration of medications for two residents, resulting in significant medication errors. Additionally, the facility failed to prevent a fall during a mechanical lift transfer, causing actual harm to a resident. The facility did not conduct adequate root cause analysis or staff re-education following the fall.

The complaint investigation found substantiated medication administration delays for Residents #2 and #3, and a fall incident involving Resident #1 during a hoyer lift transfer that caused a new large posterior scalp hematoma and left ankle trauma. The facility failed to conduct root cause analysis or provide adequate staff re-education after the fall.

The facility failed to ensure residents were free from significant medication errors, with two residents receiving medications late beyond the acceptable one-hour window. Additionally, the facility failed to prevent a fall during a mechanical lift transfer, resulting in actual harm to a resident. The facility did not conduct adequate root cause analysis or staff re-education following the fall.

The facility failed to establish and maintain an effective infection control program, particularly failing to ensure appropriate use of personal protective equipment (PPE) by staff when caring for a resident positive for COVID-19. Multiple staff members were observed not wearing N95 masks or eye protection and not sanitizing hands properly during PPE donning and doffing.

The facility was found deficient in maintaining a sanitary and safe environment, including environmental repairs, food safety and preparation, infection control practices, emergency equipment readiness, ventilation, and safety of resident areas such as patios and showers.

The facility failed to ensure appropriate use of personal protective equipment (PPE) by staff and visitors when providing care to Resident #136 in isolation for COVID-19. Multiple staff and a hospice caseworker were observed not wearing N95 masks or eye protection, failing to sanitize hands before and after PPE use, and improper doffing and disposal of PPE, increasing risk of infection transmission.

The facility was found deficient in multiple areas including maintaining a sanitary and comfortable environment, ensuring safety of exit doors, accommodating resident food preferences, food safety and sanitation practices, infection control including PPE use, emergency equipment maintenance, backflow prevention in showers, and ventilation in resident bathrooms.

The investigation was complaint-driven, triggered by allegations of failure to involve family in care planning, inadequate bathing and hygiene, medication errors, pressure ulcer prevention failures, pain management deficiencies, food service issues, dietary noncompliance, and infection control lapses during a COVID-19 outbreak.

The facility was found deficient in multiple areas including failure to involve family in care planning, honoring resident preferences for bathing, ensuring physician orders for IV fluids, preventing pressure ulcers, managing resident pain effectively, serving palatable and safe food, accommodating dietary allergies and preferences, and maintaining infection control protocols including PPE use and COVID-19 testing procedures.

The facility was found deficient in multiple areas including failure to ensure resident rights to be informed and participate in care, failure to honor resident shower preferences, failure to provide physician orders for IV fluids, development of an avoidable pressure ulcer, inadequate pain management, serving food that was not palatable or at proper temperature, failure to accommodate resident allergies and diet textures, and failure to maintain an effective infection control program including improper PPE use and inadequate COVID-19 testing procedures.