The Guardian Center

In the surveyor’s words

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

• Actual harm, patternF675Nov 10, 2022

  Based on observation, record review, and interview the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for four Residents (#89, #69, #22, and #29), out of a total sample of 27 residents. Specifically, the facility failed: 1. For Resident #89, to implement the Resident's interdisciplinary care plan for activities which resulted in a decline in the Resident's psychosocial well-being; 2. For Resident #69, to implement the Resident's interdisciplinary care plan for his/her dominant language and failed to support the Resident's cultural and activities preferences; 3. […]

• Actual harm, isolatedF684Nov 10, 2022

  Based on observations, interviews, and record review, the facility failed to ensure quality of care was provided, according to the plan of care, facility protocols, and professional standards of practice for three Residents (#32, #55, and #69), out of 27 total sampled residents. Specifically, the facility failed: 1. For Resident #32, to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice by failing to conduct ongoing assessment of a change in condition, inform the Physician of the change, and provide necessary care and treatment for a Resident with a hematoma (collection (or pooling) of blood outside the blood vessel) and worsening pain and swelling; 2. […]

• Actual harm, isolatedF740Nov 10, 2022

  Based on observations, interviews, and record review the facility failed to ensure behavioral health services were provided to Resident #63 with major depressive disorder, who exhibited frequent crying. The total sample was 27 residents. Findings include: Review of the facility's policy titled Depression-Clinical Protocol, dated as revised November 2018, indicated the following: -the physician will identify the need for additional consultation (psychiatric, psychological, etc) to help define the nature, severity, causes and complications of any mood disorder Resident #63 was admitted to the facility in July 2022 with a diagnosis of dementia, major depressive disorder (recurrent severe without psychotic features) and anxiety. […]

• Actual harm, isolatedF656Jan 22, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members for transfers, the Facility failed to ensure staff implemented and followed his/her plan of care, when on 08/26/20, Certified Nurse Aide (CNA) #1 used a slide board without the assistance of another staff member to transfer Resident #1 from his/her wheelchair to his/her bed, as a result Resident #1 fell and sustained a right arm fracture. Findings Include: The Facility's Policy titled, Falls Management, dated 02/2020, indicated that patients will be assessed for falls as part of nursing assessment process, and those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. […]

• Actual harm, isolatedF689Jan 22, 2021

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the assistance of two staff members for transfers, the Facility failed to provide the necessary level of assistance to maintain Resident #1's safety when on 08/26/20, Certified Nurse Aide (CNA) #1 used a slide board without the assistance of another staff member to transfer Resident #1 from his/her wheelchair to his/her bed, as a result Resident #1 fell and sustained a right arm fracture. Findings include: The Facility's Policy titled, Falls Management, dated 02/2020, indicated that patients will be assessed for falls as part of nursing assessment process, and those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. […]