Guardian Angels Health & Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 31, 2024

  Based 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. […]

• Actual harm, isolatedF697Nov 12, 2024

  Based 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. Findings include: R1's Face Sheet dated 10/15/24, identified R1 had diagnoses of chronic pain syndrome. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact, had pain, and used as needed pain medications. […]

• Actual harm, isolatedF684Sep 25, 2023

  Based 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. Findings include R1's Face Sheet identified R1 had diagnosis of Parkinson's disease R1's quarterly Minimum Data Set (MDS) dated [DATE] identified R1 had moderate cognitive impairment. Required assist of one for bed mobility, dressing, toilet use, and assist of two for transferring. R1's care plan dated 1/30/22, identified R1 required assist to safely transfer from one surface to another and staff were to monitor for changes in abilities. […]

• Actual harm, isolatedF684Aug 3, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Jul 30, 2026

  Based 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.Findings include:According to the ASHRAE (American Society of Heating, Refrigeration and Air-conditioning Engineers) Standard 188 - Legionellosis: Risk Management for Building Water Systems, dated 10/2015, there are seven key elements of a Legionella water management program: -Establish a water management program (WMP) team-Describe the building water systems using text and flow diagrams-Identify areas where Legionella could grow and… […]