Ark Healthcare & Rehabilitation at Governors House

In the surveyor’s words

From the most serious findings on record at Ark Healthcare & Rehabilitation at Governors House, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 13, 2024

  Based on observations, review of the clinical record, staff interview, and review of facility documentation for 1 of 3 residents (Resident #39) reviewed for pressure ulcers, the facility failed to ensure off-loading of the heels was implemented to prevent a pressure ulcer. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnosis of cerebral vascular infarction (CVA), pleural effusion, and hemiplegia/hemiparesis. A Discharge Summary from the hospital dated 10/20/23 identified Resident #39's skin was without rashes, ulcerations, or petechiae. An Admission Braden scale dated 10/20/23 identified Resident #39 was at moderate risk for skin breakdown. […]

• No harm, potential for more than minimal, widespreadF880Mar 13, 2024

  Based on the staff interviews, facility documentation, and review of the facility policies, the facility failed to ensure that Infection Prevention Control Program standards (IPCP) policies and procedures are reviewed annually by the Administrator, Medical Director, and the Director of Nursing and that the facility maintained an updated list of residents with Multidrug Resistant Organism. (MDRO) The findings included: On 3/1/24 at 11:07 AM, review of the Infection Prevention policies/procedure manual with RN #6 (the Infection Preventionist) and RN #7 (the previous Infection Preventionist) failed to identify the policies had been reviewed and signed by the Administrator, Medical Director, and Director of Nursing annually. […]

• No harm, potential for more than minimal, patternF761Dec 30, 2025

  Based on observations, review of facility policy and procedures, and interviews reviewed for one of two medication storage rooms, the facility failed to ensure that expired testing supplies were removed from medication room, facility failed to ensure items were not stored on the floor, facility failed to ensure staff personal food items were not being stored in the medication room and failed to ensure medication refrigerator temperatures were consistently completed. The findings include:1. […]

• No harm, potential for more than minimal, patternF812Dec 30, 2025

  Based on observations, review of facility policy and procedures and interviews, the facility failed to ensure the nourishment room refrigerator and room were cleaned and kept in a sanitary manner. The findings include:Based on observations, review of facility policy and procedures and interviews, the facility failed to ensure the nourishment room refrigerator and room were cleaned and kept in a sanitary manner. The findings include: An observation of the nourishment room on the second-floor unit with the DNS on 12/22/25 at 2:17 PM identified immediately upon entrance the nourishment room has a foul odor. The DNS indicated she smelled a foul odor and the longer she was in the room it did not smell, however immediately upon entering there was an odor. […]

• No harm, potential for more than minimal, patternF756Mar 13, 2024

  Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 5 residents (Resident #7 and Resident #43) reviewed for unnecessary medication, the facility failed respond to pharmacy recommendations related to an as needed (PRN) psychotropic medication. The findings include: 1. Resident #7's diagnoses included Alzheimer's disease, anxiety disorder and Type 2 diabetes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 was moderately cognitively impaired, required practical assistance with shower transfer and toileting hygiene and maximal assistance with showering. The Resident Care Plan dated 11/10/23 identified Resident #7 had episodes being resistive to care- refused to shower and refused to change clothes. […]