Angels Nursing Health Center

In the surveyor’s words

From the most serious findings on record at Angels Nursing Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Apr 30, 2024

  Based 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 [DATE], 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 [DATE]. - Develop comprehensive person-centered Dysphagia (difficulty swallowing) care plan, per the facility's Comprehensive Plan of Care policy. […]

• Immediate jeopardy, isolatedF813Apr 30, 2024

  Based 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). […]

• Actual harm, isolatedF689Jul 16, 2024

  Based 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). […]

• Actual harm, isolatedF689Apr 30, 2024

  Based 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. […]

• Actual harm, isolatedF689May 24, 2022

  Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had dementia (loss of memory, thinking and reasoning), was a high risk for falls and was diagnosed with [CONDITION(S)] (serious mental disorder in which people interpret reality abnormally, may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior), was provided a low bed and floor mats, per facility's Fall Prevention Program policy and failed to notify the physician of Resident 1's altered behavior / change in condition. […]