Guardian Angels Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a comprehensive bowel and bladder assessment and develop an individualized incontinence care plan with goals and interventions to maintain or improve continence status for 1 of 3 (R6) reviewed for urinary incontinence.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a dignified living existence for 3 of 3 residents (R1, R2, and R3) reviewed for call lights. Staff responded timely to the residents when the residents pressed their all lights for assistance; however, the staff would turn off the call light not providing services. This practice resulted in R1 and R2 soiling themselves and R3, a non-weight bearing resident attempted to transfer herself to the bathroom.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders and ensure provider was notified of resident refusals for continuous positive airway pressure (CPAP) orders for 1 of 1 residents (R2) reviewed respiratory care.

Inspectors wroteKitchen On 1/21/25, at 9:32 a.m., during a brief initial tour with the interim culinary director (CD)-A and the certified dietary manager (CDM), an observation was made of completion of the dishwashing process. At that time, the temperatures for the morning cycle temperature check had not been logged. Dietary aide (DA)-B stated the wash temp was 150 degrees Fahrenheit, and the rinse temp was one hundred and eighty five-ish. DA-B stated the temperatures were to be 160 for wash, and 180 for the rinse cycle. Although able to state the desired temperatures for the wash and rinse cycle, DA-B stated she was unaware the temperatures were to be up to the desired temperatures before starting the dishwashing process and was unaware there were further interventions indicated if the machines did not reach the desired temperatures. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, and take timely action to correct the temperatures, for 1 of 1 dishwashers observed. This had the potential to affect all 108 current residents, as well as staff, who ate food served from dishes and tableware that were cleaned in the dishwasher.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide activities of daily living (ADL's-dressing, grooming, bathing, eating, and grooming) for 4 of 4 residents, ( R57, R46, R16, R14) who were observed for assistance with eating.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was held at a steady temperature of greater than 140 degrees Fahrenheit for palatability, for 4 of 4 residents, ( R57, R46, R16, R14) observed during the dining process.

Inspectors wroteBased on observation, interview, and document review the facility failed to provide assist with personal grooming for 1 of 1 residents, (R2), reviewed for personal appearance.

Inspectors wroteBased on interview and document review, the facility failed to ensure the completed quarterly Minimum Data Set (MDS) was accurately coded to reflect hospice services for 1 of 1 resident (R15) reviewed for MDS' accuracy.

Inspectors wroteBased on interview and document review, the facility failed to ensure medications were administered per physician's order for 1 of 1 resident (R21) reviewed for bowel management.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the call light was accessible for 1 of 4 residents (R4) reviewed for accommodation of needs.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents with food allergies received the appropriate meal tray for 1 of 3 residents (R1) reviewed for food allergies. This resulted in an Immediate Jeopardy (IJ) when R1 ingested an allergen, and was hospitalized in an intensive care unit (ICU). The provider had already implemented corrective action prior to the investigation, so the deficiency is issued as past non-compliance. The IJ began on 7/10/24, at 5:04 p.m., when R1 was served and consumed food she was known to be allergic to. The administrator and director of nursing (DON) were informed of the IJ on 7/17/24 at 4:05 p.m. The facility implemented corrective action on 7/11/24, prior to the start of the survey and was therefore Past Non-compliance.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide care planned supervision to prevent falls for 1 of 3 residents (R1) reviewed for accidents. This resulted in an immediate jeopardy (IJ) situation for R1 when she sustained a right femur (leg) fracture during a fall that required surgical intervention while attempting to self-transfer unsupervised in the bathroom. The immediate jeopardy began on 5/6/24, when nurse aid (NA) assisted R1 to the bathroom, left her on the toilet, and exited the bathroom. While R1 was in the bathroom alone, she stood up and fell to her right side which resulted in a two-inch laceration to left forearm, two skin tears, two centimeters (cm), on right knee, and two skin tears above right knee. R1 rated right hip/leg pain at 8/10 (0-to-10 Pain Scale, this scale uses numbers from 0 to 10. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure advanced directives were accurately documented on the resident's electronic health record (EHR) banner, physician orders and Physician's Orders for Life Saving Treatment (POLST) which affected 2 of 32 residents (R24 and R79) reviewed for advance directives. This resulted in an immediate jeopardy (IJ) for R24 who would have been denied cardiopulmonary resuscitation (CPR) contrary to their wishes, in the absence of a pulse or respirations and for R79 who would have received CPR contrary to their wishes in the absence of a pulse or respirations. The administrator was notified of the IJ on [DATE] at 2:33 p.m. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to assess residents for the ability to self administer nebulizer treatments after nurse set up for 1 of 1 residents (R270) observed self administrating a nebulizer treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and maintain recommended restorative programming for 1 of 1 residents (R71) who were reviewed for treatment and services to prevent further decrease in range of motion (ROM).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure post-dialysis assessment and monitoring was completed for 1 of 1 residents (R40) reviewed for dialysis.

Inspectors wroteBased on interview and document review the facility failed to ensure resident protection pending an investigation into an allegation of abuse.