Guardian Angels Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Jan 24, 2025

  Based on observation, interview and document review the facility failed to implement infection control strategies for respiratory protection to mitigate the risk and spread of Influenza A and norovirus. In addition, the facility failed to ensure infection control measures were implemented to reduce the spread of Norovirus when the dishwasher temperature did not rise high enough to sanitize the dishes during the norovirus outbreak. As a result, the facility developed an influenza outbreak which included three residents (R26, R29, and R71) who tested positive for Influenza A, and two residents who were suspected to have Influenza A (R54, and R216) as well as 10 residents (R87, R207, R346, R54, R84, R85, R23, R205, R216 and R209) who showed signs and symptoms and/or were confirmed to have… […]

• Immediate jeopardy, isolatedF806Jul 17, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689May 16, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF578Apr 11, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF600Oct 8, 2021

  Based on interview and document review, the facility failed to ensure 1 of 2 allegations of abuse were reported to the state agency (SA) immediately, but not later than two hours, and 1 of 3 residents (R1) was subsequently free from physical abuse. This deficient practice resulted in an immediate jeopardy (IJ) for R1 who was noted to suffer physical injuries after an interaction with facility staff. The IJ began on 10/1/21, at 7:46 p.m. when R1 was heard screaming in her room when alone with nursing assistant (NA)-A. NA-A exited R1's room, did not respond to her screaming, and R1 was found bleeding with newly identified injuries to her elbow and forehead. The administrator and director of nursing (DON) were notified of the IJ on 10/7/21, at 1:32 p.m. […]