Guggenheimer Health and Rehab Center

In the surveyor’s words

From the most serious findings on record at Guggenheimer Health and Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF686Oct 2, 2024

  Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide interventions for the prevention and/or treatment of pressure ulcers for two residents (Resident #15- R15 and Resident #24-R24) in a survey sample of 29 residents. The facility staff also failed to identify a pressure ulcer until at an advanced stage (stage III) for one resident- R15, which was harm. The findings included: 1a. For R15, who was total care, the facility staff failed to identify a pressure wound until it was at an advanced stage of III, with full thickness tissue loss. On 9/30/24 at 10:30 a.m., R15 was interviewed in their room. […]

• No harm, potential for more than minimal, patternF925Jan 7, 2026

  Based on resident interview, staff interview and facility document review, the facility staff failed to provide effective pest control on two of three nursing units (unit 2 and unit 3).The findings include:On 1/6/26 at 3:45 p.m., Resident #6 was interviewed about any concerns with pests in the facility. Resident #6 stated that he had recently seen mice in his room at night. Resident #6 stated bait boxes had been placed in the facility and in his room but that only a few mice were caught in the boxes and that the traps had not eliminated the mice. Resident #6 stated he had reported the issue to maintenance and that other residents on the unit reported seeing mice at times, especially at night. […]

• No harm, potential for more than minimal, patternF684Dec 10, 2024

  Based on staff interview and clinical record review, the facility staff failed to follow physician orders for two of twenty-one residents in the survey sample (Residents #105 and #111). The findings include: 1. Resident #105 was not administered the medications gabapentin, Wellbutrin and midodrine as ordered by the physician. Resident #105 (R105) was admitted to the facility with diagnoses that included heart failure, stroke, coronary artery disease, COPD (chronic obstructive pulmonary disease), hypotension, neuropathy and depression. […]

• No harm, potential for more than minimal, patternF761Dec 10, 2024

  Based on observation, staff interview and facility document review, the facility staff failed to properly store insulin on three out of five medication carts inspected. The findings include: A second-floor medication cart had an unopened insulin pen stored at room temperature and a vial of insulin stored with no date opened indicated on the label. Two medication carts on the third-floor unit had opened insulin pens stored beyond the 28-day limit and unopened insulin pens stored at room temperature. On 12/9/24 at 3:42 p.m., accompanied by licensed practical nurse (LPN) #1, two medication carts on the third-floor unit were inspected. Stored in the cart for rooms 300 to 311 were three Fiasp Flextouch insulin pens for a current resident. […]

• No harm, potential for more than minimal, patternF657Oct 2, 2024

  Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for five residents (Resident #78, Resident #70, Resident #83, Resident #15, and Resident #106), in a survey sample of 29 residents. The findings included: 1. For Resident #78 (R78), who had a hernia and was scheduled for surgical repair, the care plan was not revised to reflect the hernia being present nor pre-operative instructions/care that the facility needed to provide. On 10/1/24 at 8:34 a.m., R78 was interviewed in his room. R78 reported that he had a knot in his lower abdomen/groin and was scheduled to have surgery. On 10/1/24 and 10/2/24, a clinical record review was conducted. […]