Guttenberg Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF657Jul 14, 2022

  Based on record review, resident and staff interviews the facility failed to conduct quarterly care conferences and invite resident/family to attend and provide input for 1 of 12 residents reviewed (Resident #11) The facility census was 34 residents. Findings include: Review of the documentation for Resident #11 revealed an admitted to the facility of 4/12/21. Review of the most recent Minimum Data Set MDS) assessment for Resident #11 dated 4/15/22, showed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident was cognitively intact. […]

• No harm, potential for more than minimal, isolatedF658Jul 14, 2022

  Based on observation, record review, and staff interviews the facility failed to follow manufacturers recommendations for use of insulin pens for 1 of 1 residents observed receiving insulin injections (Resident #4). The facility census was 34 residents. Findings include: Review of the Physicians Orders for Resident #4 revealed current orders on 7/13/22 for the resident to receive a scheduled dose of [MEDICATION(S)] (long acting) insulin of 45 units every morning as well as an adjusted dose of [MEDICATION(S)] (short acting) insulin based on the residents blood sugar level at that time. During observation of Medication Administration on 7/13/22 at 7:00 am, Staff A (LPN) reviewed the MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF623Apr 1, 2021

  Based on observation, record review and staff interview, the facility failed to notify the ombudsman for 4 of 4 residents (#6, #20, #31 and # 76) reviewed. The facility reported a census of 30. Findings include: Record review showed Resident # 6 was hospitalized [DATE] and returned to the facility on [DATE]. Resident # 6 was hospitalized [DATE] and returned to the facility on [DATE]. Resident # 6 was hospitalized on [DATE] and returned to the facility on [DATE]. Record review showed Resident # 76 was hospitalized on [DATE] and returned to the facility on [DATE]. Record review showed Resident # 20 was hospitalized on [DATE] and returned to the facility on [DATE]. Record review showed resident # 31 was hospitalized on [DATE] and did not return to the facility. […]

• No harm, potential for more than minimal, isolatedF610Jan 12, 2021

  Based on record review and staff, resident and family interviews, and facility policy review, the facility failed to separate the alleged perpetrator from the victim for 1 of 6 sampled (Resident #1). The facility reported a census of 29. Findings include: The Intake Information sheet revealed the facility reported an allegation to the Department of Inspections and Appeals on 12/6/20. The allegation involved Staff A and Resident #1 and occurred on 12/4/20 at 7:30 p.m. The report had a Corrective Action Description of separated the aide and resident immediately and notified the local law enforcement. Review of Staff A's timecard sheet revealed Staff A worked on 12/4/20 from 2:00 p.m. until 10:00 p.m. […]

• No harm, potential for more than minimal, isolatedF686Jan 12, 2021

  Based on observation, clinical record review, staff, resident and physician interviews and facility policy review, the facility failed to ensure residents with pressures sores received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 3 sampled (Resident #4, #5 and #6). The facility reported a census of 29. Findings include: The Minimum Data Set (MDS) assessment identified the following pressure ulcer definitions: a. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. b. […]