Guardian Angels Health & Rehab Center

Inspectors wroteBased on interview and document review, the facility failed to establish, and implement, a facility-specific water management program, based on a comprehensive assessment of the building's water-system hazards, to prevent waterborne pathogens including Legionella. This deficient practice had the potential to affect the 52 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure supply and administration of ordered medications for 3 of 3 resident (R1, R2, and R3) reviewed for pharmacy services.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure there were sufficient numbers of staff to ensure all resident cares including activities of daily living (ADLs), toileting program/schedules, and check and changes, were completed timely for 4 of 5 residents (R1, R64, R16, R9), residents food requests were acted upon for 1 of 10 residents (R218), and residents were properly supervised during medication administration for 1 of 2 residents (R40). This had the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure food and beverages were monitored for safe food temperatures. This had the potential to effect all residents in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure cleaning and sanitization of surfaces for 1 of 1 resident (R59) reviewed for infection control. In addition, the facility failed to ensure proper handling of laundry to avoid contamination in the laundry area, and failed to have an active water management program. These deficient practices had the potential to impact all residents residing at the facility. R59: R59's re-entry Minimum Data Set (MDS) dated [DATE], indicated R59 was cognitively intact with the diagnoses of chronic kidney disease, resistance to vancomycin, and congestive heart failure. During a continuous observation on 6/10/25, at 9:01 a.m., licensed practical nurse (LPN-A) parked their cart outside of R59's room, donned PPE and entered R59's room. Signs on the door indicated R59 was in isolation with droplet precautions. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure there was an active antibiotic stewardship program and that antibiotic time-outs were performed for 3 of 5 residents (R28, R48, R218) reviewed for antibiotic use.

Inspectors wroteR28: R28's quarterly MDS assessment dated [DATE], indicated R28 was severely cognitively impaired with the diagnoses of Alzheimer's Disease, depression, psychotic disorder, and hallucinations. Section N. Medications indicated R28 received antipsychotic medications. R28's Care plan last revised 3/26/25, indicated R28 received antipsychotic medications and instructed AIMS assessments to be completed per policy. R28's Order Summary Active orders as of 6/18/25, contained the following orders: ---Seroquel 50 mg tablet at bedtime for Alzheimer and delusion disorder ---Seroquel 25 MG tablet give 1.5 tablet by mouth in the morning related to Alzheimer and delusional disorder. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to ensure activities of daily living (ADLs) were completed for 4 of 5 residents (R1, R64, R16, R9).

Inspectors wroteBased on observation, interview and document review, the facility failed to track bowel movements and provide related interventions for 2 of 4 residents (R9, R32), failed to monitor a resident's oxygen saturation levels per provider order for 1 of 4 residents (R9), and failed to complete ordered skin checks for a resident with a skin condition for 1 of 4 residents (R22) reviewed for quality of care.

Inspectors wroteBased on observation interview and record review the facility failed to ensure medications and biologics stored in the medication room were safely secured to prevent resident access and diversion. In addition, the facility failed to ensure safe refrigeration temperatures were maintained for medications requiring refrigeration. These unsafe practices had the potential to impact residents who received medication from the 200s/300s medication fridge and or could gain access to the mediation room.

Inspectors wroteThe facility failed to provide a requested second helping of food for 1 of 10 residents (R218) reviewed for dining.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a resident did not self-administer medications (SAM) as assessed and according to the care plan for 2 of 2 residents (R40, R219) reviewed for SAM.

Inspectors wroteBased on interview and document review the facility failed to ensure timely reveiw and revision of the care plan occured for 2of 2 residents (R41, R11) reviewed for care planning.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure competent, trained staff operated tube feeding pumps and managed tubing for 1 of 1 resident (R41) reviewed for tube feeding.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents were educated on and offered pneumococcal and influenza vaccinations upon admission for 1 of 5 residents (R38) admitted before 3/31/25 and failed to offer and educate on pneumococcal vaccinations for 1 of 5 residents (R59) who were reviewed for vaccinations.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents were educated on and offered COVID-19 vaccinations upon admission for 2 of 5 residents (R38, R59) reviewed for vaccinations.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident call lights were within reach from the bathroom floor in a resident bathroom for 1 of 2 residents (R17) and failed to ensure bathroom call light was in good repair for 1 of 2 residents (R27) reviewed for call light accessibility.

Inspectors wroteBased on interview and document review, the facility failed to ensure pain management was provided according to the residents' goals and preferences for 1 of 3 residents (R1) reviewed for pain management. This deficient practice caused actual harm for R1, who experienced unmanaged severe pain, disturbed sleep and needed two doses of his narcotic medication to receive pain control. The facility implemented immediate corrective action, prior to the survey and was issued at past non-compliance.

Inspectors wroteBased on interview and document review, the facility failed to safely use a toileting sling per manufacture's recommendations to transfer 1 of 3 residents (R1) reviewed for accidents. This resulted in immediate jeopardy (IJ) when R1 fell from a mechanical lift, sustaining subarachnoid and subdural bleeds (brain bleeds) that required a hospital admission. The IJ began on 7/25/24 at 4:10 p.m., when R1 fell from a mechanical lift. The administrator and director of nursing (DON) were informed of the IJ on 7/31/24 at 4:27 p.m. The facility had implemented corrective action on 7/26/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure unauthorized staff, visitors, and residents did not have access to medication storage area. This practice had the potential to affect all residents on the 400 hallway.

Inspectors wroteBased on observation, interview and document reviewed the facility failed to comprehensively assess and document a resident with a contracture to the right hand. This affected 1 of 3 residents (R8) reviewed for limited range of motion.

Inspectors wroteBased on interview and record review, the facility failed to comprehensively assess and care plan services for 2 of 3 residents (R162, R8) reviewed for care plan accuracy.

Inspectors wroteBased on interview and document review, the facility failed to follow provider orders for residents requiring weight monitoring for 2 of 4 residents (R42, R33) reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a rationale was documented for the order of an as needed (PRN) psychotropic (effecting the chemical makeup of the brain) medication beyond 14 days for 1 of 5 residents (R32) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 2 of 3 residents (R42, R21) who had an indwelling catheter. In addition, the facility failed to ensure EBP were put in place for 1 of 1 resident (R12) with a chronic wound. The deficient practices had the potential to place these residents at an increased risk for transmission of infection.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure required nurse staff data was posted daily before each shift, including over the weekend. This had the potential to affect all 61 residents, staff, and visitors who wish to review this information.

Inspectors wroteBased on interview, and document review, the facility failed to ensure an ordered range of motion (ROM) program was provided consistently for 4 of 4 resident (R3, R5, R6, and R7) reviewed for positioning and mobility.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess, monitor and respond to signs of stroke like symptoms for 1 of 3 residents (R1) reviewed for change of condition. The facility's failures caused an excessive delay of medical diagnoses, management, and treatment of R1's condition which resulted in actual harm to R1.

Inspectors wroteBased on interview and document review, the facility failed to ensure the physician and resident representative were timely notified of a change of condition for 1 of 3 residents (R1) who had a status change resulting in a delay of medical diagnoses and treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure anti-Parkinson's medication was administered with in accordance with manufacturer's recommendations, and physician orders to prevent or reduce the risk of adverse side effects. Additionally failed to identify, report, and analyze medication errors in accordance with facility policy and standards of practice for 3 of 3 (R1, R2, R3) residents who received anti-Parkinson's medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to monitor fluid intake and daily weights for 1 of 3 resident (R10) reviewed for hydration. R10 sustained harm when admitted to the hospital for exacerbation of congestive heart failure and increased edema caused by facilities lack of monitoring residents physician ordered fluid restriction. In addition, the facility failed to have a process for monitoring bowel status for 2 of 5 residents (R6, R19) and provide medical monitoring per physician orders for 1 of 5 residents (R4) reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise or update care plans for 3 of 7 residents (R10, R4, R43) and failed to provide quarterly care conferences for 1 of 7 residents (R28) reviewed for care planning.

Inspectors wrote880 Based on observation, interview, and record review the facility failed to have a surveillance program in place, procedure to notify staff and visitors of precautions for contact isolation. In addition, the facility staff failed to follow standard of practice for hand hygiene and catheter cath for 2 residents (R19, R2) reviewed for infection control. This had the potential to affect 65 residents in the facility.

Inspectors wroteThe facility failed to follow a self-administration of medication assessment and left medication in the room for 1 of 1 (R9) resident reviewed for self-administration of medication. R9's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R9 had moderate cognitive impairment. Diagnoses included Parkinson's, epilepsy, depression, major depressive disorder, disorientation and Delirium. R9 had delusions and hallucinations. The Care Area Assessment Summary (CAA)-Focus areas to provide specialized, resident specific care, included Delirium, cognitive loss/dementia, psychosocial well-being and psychotropic drug use. R9's care plan undated, indicated cognitive impairment and behaviors. During an observation on 7/31/23 at 3:43 p.m., on R9's dresser included a bottle of saline nasal spray. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the grab bar was secured appropriately to accommodate needs and promote independence with bed mobility for 1 of 1 resident (R6) who had concerns about a loose grab bar .

Inspectors wroteBased on interview and document review, the facility failed to ensure conflicting directives for emergency care and treatment were clarified to ensure resident wishes would be implemented correctly in an emergent situation for 1 of 1 residents (R53) reviewed for advanced directives.

Inspectors wroteBased on interview, and record review the facility failed to provide a written bed hold to resident and or family for 1 of 1 resident (R28) who was transferred to the hospital for medical evaluation.

Inspectors wroteBased observation, interview and document review the facility failed to provide timely assistance with toileting for 1 of 2 (R6) residents who required staff assistance with toileting.

Inspectors wroteBased observation, interview and document review, the facility failed to provide timely assistance with repositioning to prevent the worsening or development of pressure ulcers for 1 of 3 (R19) reviewed pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to ensure restorative therapy services were completed for 2 of 2 (R32, R28) residents evaluated for range of motion.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide sufficient staffing was available in order to ensure appropriate and timely care was given to 3 of 3 residents (R 6, R28, R32) who were to received range of motion, and provide timely assistance with toileting.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a resident's room was free from urine odors for 2 of 21 residents (R53, R12) whose rooms were reviewed for odors.