Guardian Care Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 29, 2023

  Based on observation, interview, and record review, the facility failed to prevent a vulnerable and severe cognitively impaired resident from exiting the facility unsupervised, and failed to provide adequate supervision and a secure environment for 1 of 3 residents reviewed for elopement, out of a total sample of 29 residents, (#70). On 7/07/23 at approximately 7:05 PM, the facility failed to prevent a vulnerable, cognitively impaired resident with known behaviors of wandering and at high risk for elopement from exiting the facility unsupervised through the unalarmed dining room doors. The facility was unaware of resident #70's whereabouts for 2 hours until a Certified Nursing Assistant (CNA), who was on break, noticed the resident in the rear parking lot. […]

• Immediate jeopardy, isolatedF686Jun 3, 2021

  Based on interview and record review, the facility failed to provide the necessary care and services to prevent the development of new advanced stage pressure ulcers for 1 of 4 residents reviewed for pressure ulcers out of a total sample of 8 residents, (#1). This failure placed resident #1 at a likelihood for serious harm, illness, and impairment (loss of limb). Resident #1 was admitted to the facility on [DATE] for rehabilitation after a fall at home. Approximately 4 weeks after admission to the facility, on 4/25/21, resident #1's wife informed the facility of a new area of skin breakdown. […]

• No harm, potential for more than minimal, widespreadF851Mar 12, 2025

  Based on record review, and staff interview, the facility failed to submit the Payroll Based Journal (PBJ) for the 4th quarter in the fiscal year (FY) 2024. Findings: Review of the Centers for Medicare and Medicaid Services (CMS) PBJ Staffing data report Certification and Survey Provider Enhanced Reports (CASPER Report 1705D) revealed no facility staffing data was submitted for the period of July 1,2024 to September 30, 2024 (FY Quarter 4 2024). On 3/12/25 at 5:08 PM, the Administrator acknowledged the facility was supposed to submit the PBJ staffing data and stated she was aware it had not been submitted for Quarter 4 of 2024. She explained that at that time there was a glitch in the system, and due to turnover in their Human Resources department it had not been submitted.

• No harm, potential for more than minimal, patternF644Mar 12, 2025

  Based on observation, interview, and record review, the facility failed to complete a Pre Admission Screening And Resident Review (PASARR) Level I Screen for 5 of 6 residents reviewed for PASARR that were later identified with a possible Serious Mental Illness (SMI), of a total sample of 34 residents, (#20, #42, #72, #28, and #75). Findings: 1. Review of the medical record revealed resident #20, a [AGE] year old female was admitted to the facility from an acute care hospital with diagnoses that included lack of coordination, ulcer of esophagus, hypertension, cerebral infarction (stroke), hemiplegia/hemiparesis (paralysis), major depressive disorder, unspecified psychosis, and anxiety disorder. […]

• No harm, potential for more than minimal, patternF812Mar 12, 2025

  Based on observation, and interview, the facility failed to store food in accordance with professional standards for food service safety, which had the potential to affect all residents who ate meals prepared in the facility's kitchen. Findings: On 3/09/25 at 9:50 AM, during the initial kitchen tour with the morning (AM) cook M, it was noted the walk-in refrigerator temperature was not written on the temperature log for today or yesterday. [NAME] M acknowledged the temperatures were not on the log and explained she was about to enter the temperature for today. In the walk-in there was a half-full bag of shredded cheese that did not have the date it was opened. […]