The Guest House Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Jul 31, 2024

  Based on interviews and record reviews, the facility failed to ensure nursing staff communicated a significant change in condition to the resident's physician for 1(#1) of 3 (#1, #2, #3) residents reviewed for notification of change. This deficient practice resulted in an Immediate Jeopardy situation on 07/13/2024 at 5:24 a.m., when Resident #1, a resident who at baseline was active and could independently ambulate, complained of pain to the lower extremities, exhibited swelling to the left knee, and was unable to bear weight or ambulate. S3LPN failed to report Resident #1's significant change in status to the medical provider on call immediately. Resident #1 continued to decline in activities of daily living until 07/15/2024 around 8:00 a.m. […]

• Immediate jeopardy, isolatedF684Jul 31, 2024

  Based on interviews and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice when the nursing staff failed to recognize, monitor, intervene, and document a resident's significant change in condition to avoid delayed treatment for 1(#1) of 3 (#1, #2, and #3) residents reviewed for injuries which required hospitalization . This deficient practice resulted in an Immediate Jeopardy situation on 07/13/2024 at 5:24 a.m., when Resident #1, a cognitively impaired resident who at baseline ambulated independently without pain, was observed by staff to have new onset pain to the lower extremities, swelling to the left knee, and was unable to bear weight or ambulate. […]

• No harm, potential for more than minimal, widespreadF880Apr 30, 2025

  Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff performed hand hygiene and proper glove use for 11 (#3, #14, #20, #26, #30, #33, #39, #54, #61, #65, and #67) of 13 (#3, #4, #14, #20, #26, #30, #33, #39, #54, #61, #65, #67, and #80) resident's observed for incontinence care. Findings: Review of the facility's policy titled, Perineal Care Policy and Procedure with an effective date of 11/17/2015, revealed the following, in part: Purpose: 2. To prevent infection . Procedure: 5. Wash hands. 6. Put on disposable gloves. 13. Female perineal care. 14. […]

• No harm, potential for more than minimal, widespreadF578Apr 18, 2024

  Based on record review and interviews, the facility failed to ensure a resident's advanced directive was honored for 1 (#1) of 3 ( #1, #2, and #3) residents reviewed for advanced directives. Findings: Review of the facility's policy and procedure titled, Cardiopulmonary Resuscitation (CPR) read in part: Procedure: 1) Assess the resident to determine if he/she is unconscious. While checking for responsiveness, check to see if the patient is apneic or only gasping, assume that he/she is in cardiac arrest. 2) Delegate a specific individual to check the resident's advance medical directive, orders and care plan for CPR or no CPR order; have individual call paramedics, attending physician and administrative personnel per facility procedure and report back to you as soon as possible. […]

• No harm, potential for more than minimal, patternF600Jun 4, 2026

  Based on observations, interviews and record review, the facility failed to protect the resident's right to be free from physical and mental abuse by Resident #86 for 4 (#19, #46, #61, and #63) of 5 residents reviewed for abuse. Findings: Review of the Policy, Abuse- Prevention and Prohibition Policy and Procedure, dated 03/25/2023 revealed the following: Policy: To provide a safe, abuse free environment for all residents. Types of abuse- Abuse is the willful infliction of injury, intimidation with resulting in physical harm, pain or mental anguish. Our policy presumes that abuse of any resident, even a resident in a coma, causes physical harm, pain, or mental anguish. […]