Central Health Care Center

In the surveyor’s words

From the most serious findings on record at Central Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 5, 2025

  Based on interviews and document review, the facility failed to conduct comprehensive elopement risk assessments for 2 of 3 residents (R1, R3) identified as an elopement risk. Additionally, the facility did not promptly respond to a sounding Wanderguard alarm or ensure proper functioning of alarmed exit doors. This resulted in an immediate jeopardy when R1 left the facility and was found half a mile from the facility.The IJ began on [DATE], when it was identified R1 had eloped through the facilities south door, with the alarm sounding and walked 0.5 miles away from the facility. On [DATE] at 1:26 p.m., the director of nursing (DON) and business office manager were notified of the IJ. […]

• Actual harm, isolatedF689Aug 3, 2023

  Based on observation, interview, and document review the facility failed to comprehensively assess each fall to identify and analyze causal factors for potential root cause in order to determine individualized interventions to prevent or decrease the risk for future falls for 2 of 3 residents (R3 and R2) reviewed for falls. The facilities failure resulted in actual harm when R3's fall required emergency services with sutures to repair a deep laceration to the face. Findings include: During an observation and interview on 8/2/23 at 3:48 p.m. R3 was seated in his wheelchair to the left of his bed watching television. R3 stated the staff are nice, but it would be nice if they would help me walk. R3's care plan dated revised 2/1/23 indicated urinary incontinence related to advanced dementia. […]

• No harm, potential for more than minimal, widespreadF880Mar 10, 2025

  Based on interview and document review, the facility failed to have a documented water management program including an assessment with a description of the building water system using text and flow diagrams to identify where Legionella and other opportunistic waterborne pathogens could grow and spread. Furthermore, the facility failed to implement measures to prevent the growth of opportunistic waterborne pathogens. This had the potential to affect all residents and staff using water in the facility. Findings include: During interview on 3/10/25 at 11:29 a.m., maintenance director (MD)-A stated he did not know what Legionella was and was not aware of what he was supposed to do for water management. […]

• No harm, potential for more than minimal, widespreadF838Jan 4, 2024

  Based on interview and document review, the facility failed to ensure the facility assessment was reviewed and updated annually. This had the potential to affect all 27 residents who resided in the facility. Findings include: During an interview on 1/4/24 at 10:34 a.m., the director of nursing provided a copy of the facility assessment dated [DATE], and confirmed the assessment had not been reviewed or updated since that date, more than one year ago. During an interview on 1/4/24 at 10:57 a.m., the administrator, who had been employed at the facility less than five months, had not been aware the facility assessment had not been reviewed in 2023. […]

• No harm, potential for more than minimal, widespreadF835Aug 3, 2023

  Based on observation, interview and document review, the facility failed to provide administration to oversee that the facility had adequate resources and guidance for appropriate resident care related to falls. This deficient practice had the potential to affect all 27 residents residing in the facility. Findings include: Refer to F689. The facility job description, Administrator undated, indicated, nursing home administrators supervise clinical and administrative affairs of nursing and rehabilitation facilities. Typical duties include overseeing staff and personnel, financial matters, medical care, medical supplies, facilities, and other duties as specific positions demand. Policy indicated that the administrator is supervised by the Board of Directors. […]