Central Guest House Healthcare & Rehabilitation Ce

In the surveyor’s words

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

• Immediate jeopardy, patternF678Mar 3, 2023

  46642 47732 Based on interviews and record reviews, the facility failed to ensure an effective system was in place for advanced directives. The facility failed to ensure: 1. Advanced directives were correctly implemented for 1 (#143) of 4 (#143, #344, #345, and #346) residents reviewed that expired; and 2. Resident's medical records accurately reflected the residents' wishes for emergency basic life support for 3 (#81, #112, and #136) of the 30 sampled and 3 random residents reviewed for Advanced Directives. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 5:45 a.m., when S8LPN stopped performing CPR on Resident #143 due to a discrepancy in the resident's code status. […]

• Immediate jeopardy, patternF835Mar 3, 2023

  Based on record review and interviews, the facility failed to be administered in a manner which enabled the effective and efficient use of resources to ensure an effective system was in place to ensure Advance Directives would be followed appropriately for 4 (#81, #112, #143, and #136) of the 30 sampled and 3 random residents reviewed for Advanced Directives. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 5:45 a.m., when S8LPN stopped performing CPR on Resident #143 due to a discrepancy in the resident's code status. S8LPN performed CPR for 5 minutes before stopping after a facility staff discovered Resident #143 had conflicting advance directive wishes that designated both DNR and full code status. […]

• Immediate jeopardy, patternF600Mar 4, 2021

  Based on observations, interviews, and record reviews, the facility failed to ensure there was a system in place to protect residents from sexual abuse for 3 (#1, R2, and R3) cognitively impaired female residents out of a total of 9 (#1, #2, #3, #6, #7, #8, R1, R2, R3) sampled residents reviewed for abuse. The facility failed to ensure: 1. Staff recognized all types of sexual abuse; and 2. Staff protected female residents (#1, R2, and R3) from two aggressive male residents (#2 and #3) who displayed continued sexual aggression. The deficient practice resulted in an immediate jeopardy situation for Resident #1 on 11/26/2020, when S8LPN found Resident #1, who was incapable of consenting to a sexual relationship, lying in Resident #2's bed. Resident #2 was laying on top of Resident #1. […]

• Immediate jeopardy, patternF607Mar 4, 2021

  Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent sexual abuse for 3 (#1, R2, and R3) of 9 (#1, #2, #3, #6, #7, #8, R1, R2, R3) residents reviewed. The facility failed to implement written policies by failing to: 1. Identify behaviors as sexual abuse when 2 (#2 and #3) residents exhibited sexually inappropriate behaviors towards female residents; 2. Investigate reported incidents involving allegations of sexual abuse by 2 (#2 and #3) male residents; 3. Protect 3 (#1, R2, and R3) cognitively impaired female residents from sexual abuse; and 4. […]

• Immediate jeopardy, patternF835Mar 4, 2021

  Based on observations, interviews, and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure 3 (#1, R2, and R3) of 9 (#1, #2, #3, #6, #7, #8, R1, R2, and R3) residents reviewed were free from sexual abuse by failing to: 1. Protect 3 (#1, R2, and R3) cognitively impaired female residents from sexual abuse from two male residents (#2 and #3), with known sexually inappropriate behaviors, who all resided on Hall A; 2. Identify two male residents' (#2 and #3) inappropriate sexual behaviors towards female residents as sexual abuse; 3. […]