Guardian Angels Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:R6's diagnoses list dated 3/18/26 included surgical aftercare for right hip fracture, type 2 diabetes, repeated falls and dementia.R6's admission Minimum Data Set, dated [DATE] indicated R6 had moderate cognitive impairment. R6 was frequently incontinent of bladder and needed maximum assistance from staff for transfers and toileting hygiene. The urinary incontinence care area assessment indicated urinary incontinence would be addressed in the care plan with the overall objectives to include improvement and avoid complications.R6's bladder and bowel incontinence assessment dated [DATE] identified R6 did not have an indwelling catheter and did not have a urostomy. The following sections were not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) of 15 indicating she was cognitively intact. R1 required substantial assistance with toileting hygiene, lower body dressing, personal hygiene, rolling from side to side in bed, transferring from a sitting to lying position and transferring from bed to chair. R1 was frequently incontinent of urine and stool and was not on a toileting program. R1's diagnoses included Type 2 Diabetes, cellulitis (a bacterial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R2's admission Minimal Data Set (MDS) dated [DATE], indicated R2 had diagnoses of pulmonary fibrosis (condition where the lungs become scarred and thickened, making it difficult to breathe), acute and chronic respiratory failure, chronic obstructive pulmonary disease, and obstructive sleep apnea (sleep disorder where breathing repeatedly pauses or slows down during sleep due to a blockage of the upper airway). Further, MDS revealed R2 had exhibited behavior related to rejection of care. R2's medication administration record (MAR) and treatment administration record (TAR) dated April 2025, revealed R2 had physician order's directing staff to record hours R2 kept his CPAP (a machine that uses mild alit pressure to keep breathing airways open while you…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: R57: R57's significant change Minimum Data Set (MDS) assessment of 12/15/24 identified that R57 was rarely/never understood and had severe cognitive impairment. R57's medical diagnoses included Alzheimer's Disease/Dementia, anxiety disorder, metabolic encephalopathy (change in how your brain works due to an underlying condition), seizure disorder (a sudden change in behavior, movement or consciousness due to abnormal electrical activity in the brain)/epilepsy (a group of non-communicable neurological disorders characterized by recurrent seizures), malnutrition (imbalance between the nutrients your body needs to function and the nutrients it gets), dehydration (a lack of total body water that disrupts metabolic processes ( set of life-sustaining chemical reactions in organisms), hyperosmolality ( a condition of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: R57: R57's significant change Minimum Data Set (MDS) assessment of 12/15/24 identified that R57 was rarely/never understood and had severe cognitive impairment. R57's medical diagnoses included Alzheimer's Disease/Dementia, anxiety disorder, metabolic encephalopathy (change in how your brain works due to an underlying condition), seizure disorder (a sudden change in behavior, movement or consciousness due to abnormal electrical activity in the brain)/epilepsy (a group of non-communicable neurological disorders characterized by recurrent seizures), malnutrition (imbalance between the nutrients your body needs to function and the nutrients it gets), dehydration (a lack of total body water that disrupts metabolic processes ( set of life-sustaining chemical reactions in organisms), hyperosmolality ( a condition of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: R2's quarterly Minimum Data Set (MDS) assessment of 11/16/24, identified R2 had brief interview for mental status (BIMS) score of 12. Although classified as moderate cognitive impairment, a score of 13 indicates intact cognition. A listing of R2's medical diagnoses included progressive neurological conditions, cerebral palsy (a group of conditions that affect movement and posture), dementia, and multiple sclerosis (MS-a disease that causes breakdown of the protective covering of nerves which can cause numbness, weakness, trouble walking, vision changes and other symptoms). The MDS indicated R2 had functional limitation of both upper extremities and was fully dependent of staff for all aspects of personal hygiene, including combing her hair, shaving, washing and drying face and hands. A review of R2's care plan, most recently revised on 6/3/24, indicated R2 had an ADL (activities of daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: The CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2023, identified each section of the MDS along with various instructions how to code and/or complete them. The section labeled, Section O: Special Treatments, Procedures, and Programs, listed directions to record any special treatments or programs the resident received during the specified time period (i.e., assessment reference date; ARD). This included, . Hospice Care, and outlined, Code residents identified as being in a hospice program . where any array of services is provided for the palliation and management of terminal illness . R15's quarterly MDS dated [DATE], identified diagnoses included progressive neurological conditions, neurogenic bladder, dementia, Parkinson's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 had intact cognition and required assistance with all activities of daily living (ADL)'s except upper body dressing, eating and oral hygiene. R21's diagnoses included neuromyelitis optica, hypertension, multi-drug-resistant organism (MDRO), paraplegia, malnutrition, cutaneous abscess of buttock and osteomyelitis. During review of R21's electronic medication record (EMR), R21 had an order for senna-docusate sodium oral tablet 8.6-50 mg (milligram) one tablet twice daily to prevent constipation, oxycodone 5 mg one tablet by mouth every four hours as needed for pain, and senna-docusate sodium oral tablet 8.6-50 mg one table by mouth as needed for constipation twice daily - take one or two tablets. R21's bowel record indicated R21's last bowel movement was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R4's quarterly Minimal Data Set (MDS) dated [DATE], had diagnoses of anxiety, depression, and was cognitively intact. R4 was noted to have lower extremity impairment on both sides. R4's care plan dated 8/10/23, indicated R4 had a mobility deficit due to adult failure to thrive, was non-ambulatory, and was dependent on staff for wheelchair mobility. On 9/11/24 at 4:11 p.m., upon entering R4's room, R4 stated I don't have my call light. R4 was observed sitting in her standard wheelchair next to her bed, facing the window and her back was to the door. R4's call light was observed on the bottom right-hand corner of her bed next to the wall. R4's bedside table was to the right of her in between her and the bed. R4 stated she was unable to self-propel in her wheelchair and depended on staff to assist with mobility. R4 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: R270's admission Minimum Data Set (MDS) date 4/9/24, indicated R270 was cognitively intact. R270's self-administration of medication evaluation dated 4/8/24, indicated R270 did not self-administer medications which included nebulizer medications after nurse set up. R270's order summary report dated 4/11/24, directed staff to administer albuterol sulfate (medication to open airways, and treat air flow blockage) nebulization solution 2.5 milligrams(mg)/3 milliliters (ML) 1 vial via nebulizer four times daily. However R270's orders failed to include a provider order to self-administer albuterol sulfate. When interviewed 4/8/24 at 1:55 p.m. R270 stated staff did not observe him while Albuterol nebulizer was administered. On 4/11/24, at 9:35 a.m. observed R270 sitting in chair in room self-administering nebulizer, resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings include: R71's Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition with a diagnoses of hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side and contracture (a shortening and hardening of muscles and rigidity in joints) of the left hand. R71's cognition was moderately impaired. R71's occupational therapy (OT) Discharge summary dated [DATE], identified a prognosis to maintain current level of function as excellent with consistent staff support and the recommendation of a range of motion program to decrease risk of increased tightness. R71's Change in Functional Status/Nursing Rehabilitation Program form dated 11/11/22, identified the therapy recommendation to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R48's admission Minimum Data Set (MDS) dated [DATE], identified R48 had intact cognition and required partial/limited assistance with all activities of daily living (ADLs). R48's diagnoses included atrial fibrillation, coronary artery disease, orthostatic hypotension, end stage renal disease, arthritis, CVA/TIA (stroke) and malnutrition. R48 received dialysis treatment that was done outside of the facility. R48's care plan dated 2/20/24, indicated R48 required hemodialysis related to end-stage renal disease and had a shunt in their left arm for vascular access. R48's care plan lacked pre- and post-dialysis instructions for monitoring of access site for shunt bruit and thrill (when the nurses listens and feels the dialysis access site to ensure blood flow). R48's Medication Administration Record (MAR) for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure resident protection pending an investigation into an allegation of abuse. Findings include: R1's admission Record indicted he admitted to the facility on [DATE] and identified diagnosis that included anxiety. R1's care plan dated 3/1/24, indicated he was alert to person, place and time and identified intact cognition. A report to the state agency (SA) dated 3/12/24, indicated R1 alleged he was physically abused by staff on 3/9/24. The report indicated the alleged abuse caused R1 great fear and anxiety and indicated he was afraid to leave his room. A second report to the SA dated 3/12/24, indicated R1 sent an e-mail to registered nurse RN-A which stated there had been conduct issues with nursing staff and requested NA-A and RN-B not provide care for him. R1 reported to RN-A he had scratches on his forearm as a result of RN-B attempting to grab his phone out of his hand. R1 further reported NA-A had called him a fat ass and said all he did was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.