Guardian Rehabilitation Hospital

In the surveyor’s words

From the most serious findings on record at Guardian Rehabilitation Hospital, in the surveyor’s own words.

• Actual harm, isolatedF744Feb 12, 2025

  Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had diagnosis of dementia (condition of a person losing the ability to think, remember and reason) and history of fall, received care and services to prevent fall by failing to: 1. Implement Resident 1's Dementia Care Plan and At Risk for Fall Care Plan to ensure: Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1 explained procedure, remind not to have position change, remind for safety, reassure resident safety, and avoid environmental hazard (using multiple ramps) to Resident 1 before transporting Resident 1 in a wheelchair. 2. […]

• Actual harm, isolatedF684Jul 9, 2024

  Based on interview and record review, the facility failed to ensure for one of four sampled residents (Resident 1) who had a change in condition (CIC- is a sudden significant deviation from a patient's baseline in physical, cognitive mental ability to make decisions), manifested by chest congestion (abnormal or excessive accumulation of a body fluid), and productive cough, was assessed without a delay in treatment by failing to: 1. Ensure Licensed Vocational Nurse 3 (LVN 3) immediately checked Resident 1's vital signs (blood pressure [BP], heart rate [HR], respirations [RR], oxygen saturation [O2 Sat - amount of oxygen in the blood] and temperature [Temp]) when Certified Nursing Assistant 2 (CNA 2) informed LVN 3 that Resident 1 had a change in condition on [DATE] at around 7:30 AM. 2. […]

• Actual harm, isolatedF689Dec 2, 2022

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was identified as a high risk for falls and with a prior history of a fall, was provided with a landing mat. This deficient practice resulted in Resident 1 acquiring a laceration on her arm, breaking her pelvis bone and sacrum (base of vertebrae connected to the pelvis) on 10/3/2022 when she fell from her bed, landing on the floor. Resident 1 was transferred to the General Acute Care Hospital (GACH) for further evaluation. Findings: A review of Resident 1's Face sheet (admission record), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including difficulty walking and muscle weakness. […]

• No harm, potential for more than minimal, widespreadF732Feb 11, 2024

  Based on observation, interview and record review, the facility failed to post daily actual hours worked by licensed and unlicensed staff providing direct care to the residents for 1/1/2023 to 2/10/2024. As a result, residents and visitors did not know the accurate number of hours of staff working. Findings: On 2/11/2024 at 11:56 AM, a review of copies of the Projected Daily Care Staffing form for the months of January and February 2024 indicated there were no actual hours worked by direct care staff posted. During a concurrent interview, the Director of Staff Development (DSD) stated she was responsible for posting the daily staffing report and that she only posted the projected staffing hours. […]

• No harm, potential for more than minimal, patternF550Mar 17, 2026

  Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 did not violate the resident's rights to be treated with respect and dignity for one of four sampled residents (Resident 1) by failing to ensure:1. CNA 1 did not record a video of Resident 1 without Resident 1 and/or Resident 1 Responsible Party 1's (RP 1) consent in multiple occassions.2. CNA 1 did not post a video of Resident 1 on social media3. CNA 1 did not take videos and use personal cellphone inside the facility and inside residents' room during working hours.These deficient practices violated Resident 1's right to be treated with respect and dignity and the potential to subject Resident 1 and other residents to humiliation (the act of being made to feel ashamed, embarrassed, or… […]