Angels Nursing Health Center

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall prevention interventions for one of four sampled residents (Resident 1). This failure resulted in Resident 1 falling a second time on 7/6/26 where the resident sustained a lip laceration and bump on her head. During a review of Resident 1's admission Record dated 7/8/26 indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dysphagia (difficulty swallowing), hypertension (HTN - high blood pressure), muscle weakness, difficulty in walking, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and anemia (a condition where the body does not have enough healthy red blood cells). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices to provide a safe, sanitary, and comfortable environment for one of two sampled medication carts (Medication cart 2) and for two of five sampled residents (Resident 34 and Resident 59) by failing to ensure:-Licensed nurses (in general) cleaned the pill cutter (safely and accurately cut medication tablets in half) in Medication Cart 2 and ensured the pill cutter did not have medication residuals inside the pill cutter.-Licensed Nurses (in general) labeled Resident 34's breathing treatment (a nebulizer machine that turns liquid medicine into a mist for inhalation) tubing and mask with date and ensure the tubing and mask were not on the floor.-Licensed Vocational Nurse 2 (LVN 2) wore a gown and gloves when checking Resident 59's blood pressure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the housekeeping standards by failing to:-Ensure a clean and sanitary dumpster area outside the facility's kitchenThis failure had the potential to cause contamination, poor sanitation in the facility and safety risks among its residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to safeguard the personal belongings for one of two sampled residents (Resident 2) by failing to: -Ensure Resident 2's clothing (in general) was labeled in accordance with the facility's policy and procedure titled Laundry-Resident clothing. This failure resulted in Resident 2's clothing to be unidentifiable, lost, and the potential to negatively affect Resident 2's dignity and right to keep personal property.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) to meet the needs of one of 15 sampled residents (Resident 34) by failing to:- Develop a care plan for Resident 34's breathing treatment (a nebulizer machine that turns liquid medicine into a mist for inhalation). This failure had the potential to result negative impact on Resident 34's health, as well as the quality of care and services received.

Inspectors wroteBased on interview, and record review, the facility failed to meet professional standards of care and practice for one of two sampled residents (Resident 37) by failing to ensure diet order was checked prior to serving Resident 37's lunch tray. This failure had the potential to negatively impact on the delivery of care service provided to Resident 37.

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective infection prevention and control program for one of five sampled residents (Resident 34) reviewed for immunizations, by failing to:- Ensure to offer Resident 34 the pneumococcal (Pneumonia [PNA]-infection that inflames air sacs in one or both lungs which may fill with fluid) vaccine, in accordance with facility policy and procedures (P&P) titled Pneumococcal Disease Prevention reviewed by the facility on 12/30/2025 and current standards of practice. This failure placed Resident 34 at a higher risk of acquiring pneumonia as well as other residents, visitors and staff within the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective infection prevention and control program for one of five sampled residents (Resident 34) reviewed for immunizations, by failing to:-Ensure to offer Resident 34 the COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) vaccine, in accordance with facility policy and procedures (P&P) titled COVID-19 Vaccination reviewed by the facility on 12/30/2025 and current standards of practice. This failure placed Resident 34 at a higher risk of acquiring COVID-19 as well as other residents, visitors, and staff within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accountability for 17 Percocet (an opioid pain medication used to relieve severe pain) tablets, schedule II Medications (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) for one of three sampled residents (Resident 1). This failure had the potential to result in a drug diversion (when a medication is taken for use by someone other than whom it is prescribed), opioid abuse (excessive use of a drug in a way that is detrimental to self, society, or both), and accidental overdose (unintentional intake or administration of a substance in doses higher than what is considered safe or recommended) for Resident 1 and or other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 5/20/2025 when: 1. Fortified Diets (Diet enriched to increase caloric content of the foods commonly consumed by the resident. The amount of calorie increase should be 300-400 per day) were not prepared and were not served to seven residents who were on a fortified diet. 2. The facility failed to ensure cooks followed the spreadsheet (food portions and serving guide) 14 residents on regular diet did not receive the seasoned peas (vegetable dish) on their plate per menu and residents who were on the renal diet (a diet intended for residents with decreased kidney function. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food and preparation practices in the kitchen by failing to: 1. Ensure Dietary Staff Dietary Aide1 (DA1) washed his hands after changing gloves and when removing the clean and sanitized dishes from the dish machine when working in the kitchen. 2. Ensure to maintain a clean kitchen when the floor and shelving in the dry storage area were dirty, one package of dried pasta was open. The Coffee machine glass gauge pipe was stained with dark brown color residue. Resident dishes were not clean and had dried white and yellow stains on them. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 35 out of 36 residents who received food from the facility.

Inspectors wrotec. During a review of Resident 28's admission Record, the admission Record indicated the facility readmitted the resident on 1/8/2025 with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and dementia (a progressive state of decline in mental abilities). During a review of Resident 28's History and Physical (H&P) dated 1/9/2025, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 28's ADA dated 1/17/2025, the ADA indicated section 2 was not completed. During a review of Resident 28's MDS dated [DATE], the MDS indicated Resident 28 had the ability to understand others however missed some part/intent of the message but comprehended most of the conversation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the appropriate Low Air Loss Mattress (LALM, a pressure-relieving mattress used to prevent and treat pressure injuries [localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device]) settings for two of six sampled residents (Resident 6 and Resident 28). This failure had the potential to place Resident 6 and Resident 28 at risk for discomfort and worsening of wounds and pressure ulcers/injuries

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform two of three sampled residents (Resident 24 and Resident 250) of the medications that were administered to them during medication pass, as per facility's policy and procedure (P&P), titled Medication Administration - General Guidelines, dated 10/2017 and nurses' education document, titled Principles of Medication Administration, dated 2/5/2025. This deficient practice failed to provide information about medications to Resident 24 and Resident 250 before administering them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner. On 5/20/2025 at 10:30AM one of the two garbage dumpsters was overfilled with trash bags and uncovered. This failure had the potential for harborage and feeding of pests.

Inspectors wroteBased on interview and record review the facility failed to investigate and determine how a resident got out of the facility for one of three sampled residents (Resident 1). For Resident 1, who was found in the facility ' s parking lot on 4/13/25, the facility failed to determine how Resident 1 left her room unattended and was found in the facility ' s parking lot. This deficient practice had the potential for Resident 1 to leave the facility unattended again and potentially be exposed to danger.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide protection from physical abuse for one out of three sampled residents (Resident 2), by failing to: 1. To follow facility policy and procedures (P&P) titled Behavior-Management, dated 2/9/2024, and document Resident 1's specific identified aggressive behaviors. Resident 1 had aggressive behaviors 17 out of 28 days in February 2025, the type of aggressive behaviors was not documented. 2. Update care plan and interventions to address increase in aggression and behavioral changes quarterly and with changes in condition (COCs) and after identified aggressive behaviors as per facility P&P titled Behavior-Management dated 2/9/2024, and P&P titled Care Planning dated 2/9/2024. As a result on 2/25/2025, Resident 1 hit Resident 2 on the chest, after Resident 2 refused to give Resident 1 money. [...]

Inspectors wroteBased on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) on 2/13/2025 to the facility after hospitalization to a General Acute Care Hospital (GACH), as indicated in the facility's policy titled Readmission. As a result, Resident 1 remained in the GACH with discharge orders written on 2/12/2025 to return to the facility. Denying the resident the right to return to their home in the facility and placing Resident 1 at risk for psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to revise a bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) care plan on a quarterly basis for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the provision of care and services for Resident 1.

Inspectors wroteBased on interview, and record review the facility failed to implement policies and procures to prevent and control the transmission of COVID-19 (coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and it spread during close contact and through the air from person to person) infection. By failing to ensure Licensed Vocational Nurse 3 (LVN 3) immediately left the facility upon testing positive for COVID-19. LVN 3 tested positive on 7/27/2024 at 7 PM and continued to work until 8 PM, charting and preparing medications for approximately 20 residents. This deficient practices had the potential to transmit infectious disease microorganisms and increase the risk of infection to all 43 residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan that meets the care/services based on the resident's individual assessed needs for one of five sampled residents (Resident 1 [R1]) by failing to ensure that a comprehensive CP was implemented for R1 risk for elopement (leaving the facility unsupervised and without staff knowledge). This deficient practice had the potential to result negative impact on residents' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1 [R1]) was properly supervised to prevent elopement (leaving the facility unsupervised and without staff knowledge) by failing to: 1. Implement the facility's policy and procedures (P&P) regarding elopement. 2. Implement the comprehensive care plan for actual episode of wandering and previous successful attempts of elopement. These deficient practices resulted in R1 eloping on 7/17/2024 and was transferred to general acute care hospital 1 (GACH 1) due to chest pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate competencies to provide nursing and related services to assure resident safety by failing to maintain and update basic life support/ Cardiopulmonary Resuscitation (BLS/CPR) certification to one of eight sampled facility staff (Certified Nursing Assistant 1- CNA1). This deficient practice had the potential to place resident at risk of not getting proper immediate care during a life-threatening situation.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five sampled resident (Resident 1-R1's) psychotropic medication regimen was managed and monitored to promote or maintain the highest practicable mental, physical, and psychosocial well-being by failing to: 1. Ensure a behavior monitoring for episodes of anxiety specific for R1's Ativan (anti-anxiety medication) use was properly ordered and implemented. 2. Ensure a behavior monitoring for episodes of psychosis specific for R1's Depakote (anti-psychotic medication) use was properly ordered and implemented. These failures had the potential to place R1 at risk of receiving unnecessary medications and/or overuse of medication; and at risk for adverse consequences while taking psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a history of falls and was assessed as high risk for falls, received the care and services necessary to prevent accidents and falls as evidenced by failing to provide the resident with assistance and supervision when ambulating (walking) to the bathroom. As a result, on 7/5/2024 (three days after admission), Resident 1 was found on the floor bleeding, and with a four-centimeter laceration (deep cut or tear in the skin or flesh) on the occipital posterior area of the head (back of the head). Resident 1 was transferred to General Acute Care Hospital (GACH) 2 where Resident 1 was diagnosed with subdural hematomas (pools of blood between the brain and its outermost covering caused by a head injury strong enough to burst blood vessels).

Inspectors wroteBased on interview and record review, the facility failed to identify and ensure one of three sampled residents (Resident 43), who had difficulty swallowing and was at risk for aspiration (accidentally inhaling your food or liquid into your airway), received necessary care and services in accordance with professional standards of practice by failing to: -Follow the Physician's Order dated 2/12/2024, for Resident 43 to receive a pureed diet (food has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding). - Assess for tolerance of diet, per the Alteration in Oral / Dental Status care plan dated 2/12/2024. - Develop comprehensive person-centered Dysphagia (difficulty swallowing) care plan, per the facility's Comprehensive Plan of Care policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 43), who had difficulty swallowing and was at risk for aspiration (accidentally inhaling your food or liquid into your airway), received care and monitoring of the resident's food consumption within the guidelines of the diet order by failing to: - Implement the facility's policy and procedure (P&P) titled, Food for Residents from Outside Sources, that food brought in from outside the facility for a resident would be first shown to the Charge Nurse for approval that the food was within the diet order (therapeutic and texture). - Implement the facility's P&P titled, Food for Residents from Outside Sources, by providing the family of Resident 43 with the information sheet, Bringing in Food for A Resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of four sampled residents (Residents 13, 29, and 36) received care and services necessary to prevent accidents and falls by failing to: -Assess Resident 13 accurately for a high fall risk on 11/3/2023. - Identify measures and interventions for risk for falls prior to Resident 13's fall on 1/20/2024. -Complete the Fall Risk Assessments quarterly for Residents 29 and 36, per facility policy. As a result, Resident 13 had a witnessed fall on 1/20/2024, was transferred to the General Acute Care Hospital (GACH) 1 and sustained an acute (new) left femoral neck fracture (hip fracture) and placed Resident 29 and 36 at increased risk for recurrent falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, sanitary environment to help prevent the spread of airborne infections (infectious agents/organisms that remain infectious over long distances when suspended in the air) by failing to fit test (check whether a respirator properly fits the face of someone who wears it) six of six sampled staff (Registered Nurse 1 (RN 1), Licensed Vocational Nurse 1 (LVN 1), LVN3, Certified Nursing Assistant 2 (CNA 2), Restorative Nurse Aide 1 (RNA 1) and [NAME] 1 (CK 1) for their N95 mask (respirator: a respiratory protective device designed to achieve a very close facial fit and provide efficient filtration of airborne particles). This deficient practice had the potential to result in respiratory infections for all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to employ an Infection Preventionist Nurse (IP) at least part time as per the facility assessment (the facility's self-evaluation of its resident population and identification of the resources needed to provide the necessary person-centered care and services the residents require) dated January 2024. This deficient practice had to potential to affect the facility's ability to prevent and manage the spread of infection and diseases.

Inspectors wroteBased on interviews and record reviews, the facility failed to submit the required complete information contained in the Minimum Data Set (MDS- a standardized data collection tool used to assess cognitive and functional status, and care needs) for four of 13 sampled residents (Resident 2, Resident 29, Resident 32, and Resident 34) within 14 days of initiation to the Centers for Medicare & Medicaid Services (CMS: a federal agency within the United States Department of Health and Human Services) System. This deficient practice had the potential to deny Resident 2, Resident 29, Resident 32, and Resident 34 proper healthcare monitoring to ensure all the necessary care and services were provided.

Inspectors wroteBased on interview and record review, the facility failed to perform required annual staff competency evaluation (an evaluation of the skills, knowledge, and abilities of a staff member) for three of seven sampled staff (Registered Nurse (RN) 2, Licensed Vocational Nurse (LVN) 1, and LVN 2). This deficient practice had the potential for residents to not receive the appropriate care and services needed, which could affect the quality of care received, and potentially lead to resident harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice and facility policy and procedures (P&P) for Disposal of Medications and Medication-Related Supplies reviewed [DATE] were followed. By failing to ensure unused medications were stored in a securely locked area. This deficient practice had the potential to result in diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber), overdose, and death.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident centered comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) for three of 13 sampled residents (Resident 9, Resident 13, and Resident 28) as evidenced by: 1. Failing to develop a care plan for Resident 9's gastrostomy tube (G-tube: a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube) and tube feeding (TF, a liquid form of food that's carried through your body through a G-tube). 2. Failing to develop a care plan with goals and interventions for pain for Resident 13's post-surgery left hip pain. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 27) received the necessary care and services to prevent complications from an Ileostomy (an opening in the abdominal wall that's made during surgery, and it is used to move waste out of the body) in accordance with the resident's comprehensive (complete/detailed) person-centered care plan. This deficient practice had the potential for Resident 27 to suffer from infection, skin breakdown, and pain.

Inspectors wroteBased on observation, interview, and record review ,the facility failed to ensure one of two sampled residents (Resident 144), who was at risk for unplanned severe weight (wt.) loss (a body weight loss of greater than five [5] percent [% - unit of measure] in one month) received the care and services necessary to prevent severe weight loss. By failing to implement Resident 144's physician's orders for weekly weights dated 4/1/2024. These deficient practices placed Resident 144 at risk for nutritional decline, dehydration, impaired healing, and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of six sampled residents (Residents 9) received the appropriate treatment and services needed to maintain and prevent tube feeding (TF, a form of nutrition that is delivered into the digestive system as a liquid) complications, as evidenced by: -Failing to ensure TF was not disconnected from Resident 9's gastrostomy tube (also known as g-tube, a small tube placed through the skin into the stomach to medicines and liquids, including liquid foods). -Failing to ensure Resident 9 was wearing an abdominal binder (a wide compression belt that encircles the abdomen; that can be used minimize inadvertent pulling or tugging of a g-tube) to secure the g-tube as per the plan of care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure therapeutic diets (a meal plan prescribed by a physician that controls the intake of certain foods or nutrients) were served for one of six sampled residents (Resident 6). By failing to ensure Resident 6 received a mechanical soft (diet is designed for people who have trouble chewing and swallowing) fortified (addition of one or more essential nutrients to a food) finely chopped diet (cut into very small and thin pieces) as per physician's orders dated 11/23/2023. This deficient practice had the potential to result in the risk for decreased nutritional intake, aspiration (accidentally inhaling your food or liquid through your vocal cords into your airway, instead of swallowing through your food pipe), and weight loss.