Centerville Specialty Care

In the surveyor’s words

From the most serious findings on record at Centerville Specialty Care, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 16, 2023

  Based on record review, and staff, hospital staff, physician and resident responsible party interviews, the facility failed to provide appropriate wound care, by competent nursing staff, consistent with professional standards of nursing practice, to promote healing, prevent infection and worsening of a pressure ulcer for 1 of 2 resident records reviewed with pressure ulcers (Resident #1). The facility reported a census of 46 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated [DATE] revealed the resident admitted to the facility [DATE] with diagnoses that included diabetes, pneumonitis due to aspiration and muscle weakness, severe cognitive impairment with symptoms of delirium present, sometimes able to make herself understood and usually able to understand… […]

• Actual harm, isolatedF580Jul 9, 2022

  Based on record review, interviews, and facility policy review, the facility failed to notify the physician of changes in condition and/or the need to alter treatment for two (Resident #311 and Resident #209) of six residents reviewed for medication administration. Specifically, the facility failed to notify the physician when Resident #311 tested positive for COVID-19, which resulted in a delay in obtaining treatment orders for the resident, who subsequently expired; Resident #311's blood sugars were out of prescribed parameters; Resident #311's medications were unavailable for administration and Resident #209 did not receive medications as ordered. The facility identified a census of 53 current residents. Findings include: 1. […]

• Actual harm, isolatedF684Jul 9, 2022

  Based on observations, record review, and interview, the facility failed to ensure three (Resident #311, Resident #29, and Resident #209) of six sampled residents reviewed for medication administration received care and treatment in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #311's physician was notified of a positive COVID-19 test on [DATE]. Once the provider was aware the resident had COVID-19 on [DATE], the facility failed to ensure physician-ordered medications were provided and tests were obtained as ordered on [DATE]. In addition, the facility failed to monitor Resident #311's vital signs for approximately 23 hours prior to the resident's death. […]

• No harm, potential for more than minimal, widespreadF812Jul 9, 2022

  Based on facility policy review, observations, staff interviews, and facility document review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to maintain safe dishwashing wash temperature of 120 degrees Fahrenheit (F) or above for a low temp machine; to serve food to residents in accordance with sanitary professional standards; to check the temperature of foods heated and reheated in the microwave; to cover meals that were sent to the outer dining area; and record, clean, and monitor a resident nourishment refrigerator. The facility identified a census of 53 current residents. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF886Jul 9, 2022

  Based on facility policy review and document review, and interviews, the facility failed to perform routine COVID-19 testing for all staff and residents per guidelines from the Centers for Medicare and Medicaid Services (CMS) QSO -20-38-NH memorandum. Specifically, the facility failed to perform routine COVID-19 testing per current guidelines when the facility was in a county with a moderate community transmission rate. This had the potential to affect all staff and residents in the facility. The facility identified a census of 53 current residents and over 48 staff members. Findings include: A review of the CMS QSO -20-38-NH memorandum, revised 03/10/2022, revealed, Routine testing of staff, who are not up-to-date, should be based on the extent of the virus in the community. […]