Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Guardian Rehabilitation Hospital during CMS and state inspections, most recent first.
A CNA repeatedly used a personal cell phone during work hours to record and post TikTok videos taken inside a resident’s room, activity/dining areas, and facility hallways, with a cognitively impaired, fully dependent resident visible in the background. The CNA admitted knowing that facility policy prohibited personal cell phone use in resident care areas and banned taking resident photos or videos without consent, yet did not obtain permission from the resident or responsible party. The resident later reported not having signed consent or given permission to appear on social media. The DSD and DON confirmed that no written consents existed, that photos/videos are allowed only for medical purposes, and that taking and posting such images without authorization violates abuse-prevention, privacy/PHI, and cellular phone policies.
Failure to follow IDDSI texture standards and standardized recipes was identified during lunch tray line service. A pureed bread item for residents on a puree diet was lumpy, had liquid separating, and left residue in the mouth; a minced and moist bread item was dry, crumbly, and had pieces larger than the fork-prong gap; and a soft and bite size hamburger was served as minced meat mixed with cheese instead of the ordered chopped texture. The DS and cooks acknowledged the items were not prepared as required by the facility recipes and IDDSI guidance.
Unsafe dish sanitizing and improper food handling were observed in the kitchen. A dietary aide and DS verified that the dish machine sanitizer was at 0 PPM instead of the required chlorine range, while washed dishes were being stored on shelves. A cook also left a wiping cloth on the counter instead of holding it in sanitizer solution, and expired ham and tuna salad were found in the walk-in refrigerator past their labeled use-by dates.
Failure to Release Lap Tray Restraint per Care Plan: A resident with DM, dementia, a fall history, and adult failure to thrive was observed in a wheelchair with a lap tray used for trunk support and to prevent falling. The resident’s care plan required the lap tray to be released at least every 2 hours and the resident repositioned, but staff could not explain whether this occurred and the DON stated the facility had no documentation of restraint monitoring or removal. The DON and ADM acknowledged the lap tray was a restraint because it restricted freedom of movement.
Failure to Rotate Insulin Injection Sites: A resident with DM and dementia received insulin glargine injections in the same abdominal site on multiple occasions instead of having sites rotated as ordered. An LVN, RN, and DON confirmed the injections were not rotated, and the DON stated the facility policy required rotation of injection sites within the same general area.
A resident with dementia, severe cognitive impairment, and limited English proficiency did not have a communication board or interpreter services available in the room. The resident spoke another language, while staff reported using English, gestures, family members, or an RN’s personal phone with Google Translate to communicate. The DON stated the facility lacked a formal translation system, and the resident’s posted menu and activity calendar were only in English.
Incorrect LALM Setting for Resident at Risk for Pressure Injury: A resident with Alzheimer's disease, malnutrition, DM2, severe cognitive impairment, and pressure injury risk was observed on a Drive LALM set between 0 and 80 lbs despite weighing 104 lbs. The LVN, RN, and DON confirmed the setting was incorrect and stated the mattress was intended to be adjusted based on resident weight and comfort.
An LVN administered cetirizine 10 mg to a resident even though the order was for 5 mg twice daily. During the med pass, the wrong-strength bottle was used, and the LVN later acknowledged the error when the surveyor reviewed the order and medication bottle. The DON stated cetirizine can cause dizziness, and the facility policy required medications to be given as prescribed and checked for the correct dosage before administration.
A dietary aide was observed sanitizing dishes with a QUAT solution but initially used the wrong test strip meant for chlorine sanitizer when checking concentration. The aide stated the normal range and testing method incorrectly before being given the correct strip, and the DS said kitchen staff needed to know how to check solutions. Record review showed annual dietary competency did not include manual dishwashing or sanitizer concentration testing, despite manufacturer instructions posted for proper testing and use.
Room Size Did Not Meet Minimum Space Requirements: The facility failed to ensure two resident rooms met the minimum square footage requirement for multiple-occupancy rooms. Observation, interview, and record review showed the facility requested a room waiver for the rooms, stating there was enough space for care, dignity, and privacy; the waiver letter listed the room measurements and staff and a resident reported there was enough room for care and therapy.
A resident admitted with a Leaf Sensor device did not receive comprehensive care as required by their care plan and physician orders. Staff were not adequately trained on the device, did not assess or document skin integrity or pain under the sensor, and failed to follow manufacturer guidelines for monitoring. The absence of proper assessment and documentation led to a deficiency in meeting the resident's individualized care needs.
A resident with multiple medical conditions was admitted with a Leaf Sensor device, but staff failed to assess or document skin integrity and pain at the device site as required by care plans, physician orders, and facility policy. Staff lacked training on the device, did not follow manufacturer guidelines, and did not document reinforcement or monitoring of the sensor, resulting in a failure to meet professional standards of care.
A resident with dementia and a history of falls was injured during wheelchair transport due to the facility's failure to implement care plans. The CNA did not provide instructions or reassurance, and chose a route with steep ramps instead of a safer flat route. The resident made a sudden movement, causing a fall and a clavicle fracture. Staff did not follow existing care plans or develop a plan for safe wheelchair transport.
The facility failed to provide appropriate care for two residents, leading to potential health risks. A resident did not have a left knee splint applied correctly, and the RNA order allowed for wearing knee splints longer than the safe duration determined by physical therapy. Another resident did not receive active range of motion exercises as ordered, which could lead to a decline in strength and function. These deficiencies were observed during RNA treatment sessions and confirmed through staff interviews.
The facility failed to complete annual competency checks for six Restorative Nursing Aides (RNAs) on the application and removal of splints and braces. An observation revealed an RNA incorrectly applied a knee splint on a resident, which was later corrected by a Physical Therapist. The Director of Staff Development confirmed the absence of these evaluations in the competency checklists, despite facility policies requiring them to ensure resident safety.
The facility failed to maintain six pieces of electrical rehabilitation therapy equipment, including bicycles and parallel bars, as per manufacturer recommendations. The equipment was not regularly checked for electrical safety or power cord damage, and maintenance was only performed if issues were reported. The lack of a maintenance policy and documentation put residents at risk of injury during therapy sessions.
A resident with severe cognitive impairment and mobility issues fell in their room due to inadequate supervision and assistance with transfers. Despite being identified as high risk for falls, the resident was found on the floor with the call light out of reach. The facility's failure to implement necessary fall prevention measures resulted in the resident being transferred to a hospital for evaluation.
A resident with COPD was receiving oxygen therapy without a physician's order and with unlabeled equipment, contrary to facility policy. The resident's nasal cannula and humidifier were not labeled, and there was no physician's order for the oxygen therapy, which is necessary for proper care. The DON confirmed that the standing order for oxygen was missed upon admission.
A resident with severe cognitive impairments and limited mobility had incomplete documentation regarding the use of knee splints. The facility failed to record the duration the splints were worn, as required by the physician's order. Observations and interviews revealed that the resident sometimes tolerated the splints for less than the prescribed time, but this was not documented, leading to inaccurate medical records.
The facility failed to meet the minimum space requirements for two resident rooms, with room 102 and room 125 falling short of the required square footage for multiple resident bedrooms. Despite this, staff and residents reported no issues with space affecting care or comfort. The facility requested a room variance, stating the rooms were adequate for residents' needs.
A facility failed to accurately assess a resident's fall history and range of motion (ROM) limitations. The resident, admitted with a history of falls and fractures, was inaccurately documented in the MDS as having no recent falls or ROM impairments. Interviews with the MDS coordinator and DON confirmed these discrepancies, highlighting the importance of accurate assessments to prevent injury risks.
A resident with severe cognitive impairment and a history of falls was left unsupervised, contrary to the IDT plan requiring a sitter from 3 PM to 7 AM. The assigned CNA left the room without notifying other staff, and the facility lacked a specific policy for sitters, contributing to the oversight.
A resident with a complex medical history experienced a change in condition, including chest congestion and a productive cough, which was not promptly assessed by the LVN or communicated to the RN. The RN failed to perform a thorough assessment or notify a doctor, resulting in a delay of over seven hours in providing necessary medical services. The resident was later found unresponsive and transferred to a hospital, where they were diagnosed with septic shock and severe dehydration, ultimately leading to their death.
A resident with multiple sclerosis and dementia resisted care and became combative during ADL assistance. A CNA continued to assist the resident despite the combativeness, as no additional help was available. The DON stated that staff should stop care if a resident becomes resistive to prevent injury. The facility's policy emphasizes treating residents with dignity, which was not followed in this case.
A resident with multiple sclerosis and dementia exhibited skin discolorations and combativeness during care, but staff failed to notify the physician or document the change of condition using the SBAR tool. The CNA delayed reporting the incident, and there was uncertainty among staff about whether proper procedures were followed.
The facility failed to document a grievance reported by a resident's family member, who found the resident in a wheelchair with no undergarments and pants below the knee. Despite notifying the head nurse, the grievance was not documented because the family member refused to discuss the issue further with the Director of Staff Development. The Director of Nursing acknowledged that a grievance report should have been completed.
A resident with severe cognitive impairment experienced nausea and vomiting after being administered cephalexin, which was not documented in the allergy profile. This led to the resident receiving the medication again and experiencing the same adverse effects. The DON and the resident's physician acknowledged the oversight.
Unauthorized Resident Video Recording and Social Media Posting by CNA
Penalty
Summary
The deficiency involves a failure to protect a resident’s rights to dignity, privacy, and confidentiality when a CNA recorded and posted videos including the resident without consent. The resident had diagnoses including dysphagia, COPD, and heart failure, and assessments showed severely impaired cognitive skills, lack of decision-making capacity, and total dependence on staff for ADLs. The resident’s care plan documented cognitive loss, short- and long-term memory impairment, poor recall, and psychosocial impairment related to psychosis and other conditions, with interventions directing staff to provide pleasant, reassuring interactions, approach the resident calmly and unhurriedly, and provide emotional support. A complaint was submitted to the District Office alleging that the CNA posted a video of the resident on social media, with two videos attached. In an interview, the resident reported that a staff member took a video of himself while the resident was in the background and that this video was posted on TikTok without the resident’s knowledge or signed consent. The resident stated he did not give permission to be posted on social media. In interviews, the CNA admitted that since November 2025 he had been taking videos and posting them on his TikTok account during work hours, including videos taken inside the resident’s room on two specific dates where the resident could be seen lying in bed in the background. The CNA acknowledged he was aware staff were not allowed to use personal cell phones during work hours or take photos or videos inside residents’ rooms, and that he did not obtain permission or consent from the resident. The DSD and DON confirmed that facility policies prohibit personal cell phone use in resident care areas, prohibit taking photos or videos of residents without written consent, and limit resident photos/videos to medical purposes only. They also confirmed there were no written consents on file for the videos taken of the resident and that taking such videos without authorization and consent is considered a type of abuse under facility policy.
Failure to Follow IDDSI Textures and Standardized Recipes
Penalty
Summary
The facility failed to follow standardized recipes and IDDSI texture requirements for multiple lunch items served on 3/2/2026. During tray line service, the pureed bread for residents on a pureed diet was observed to be lumpy, with milk floating on top in the pan. In interview, Cook1 stated the item was bread mixed with milk and blended only a little, like bread soaked in milk. A concurrent taste test with the Dietary Supervisor and cooks found the pureed bread had a lumpy texture, small pieces of bread remained in the mouth, and residue required chewing. Cook1 stated the bread had been prepared incorrectly, and the Dietary Supervisor stated the consistency was not smooth and some bread stayed in the mouth. The facility recipe for Pureed (IDDSI Level 4) breads required the finished item to be smooth, free of lumps, hold its shape, and not weep. The facility also failed to prepare minced and moist bread correctly for residents on that diet. In the kitchen, Cook1 blended hamburger buns into uneven sizes, with some particles larger than others, and stated there was nothing added for moisture. During tray line service, the minced and moist bread was observed to be dry, crumbly, not cohesive, and with larger pieces of bread; crumbly bread fell from the scoop and spread across the plate. Cook1 stated the bread was minced in the food processor without moisture added, and later acknowledged it was not moist and fell apart on the plate. The Dietary Supervisor stated some bread pieces were large and did not fit the gaps of fork prongs per the minced and moist size chart. The IDDSI Level 5 guidance reviewed by surveyors stated the food should be moist, not sticky, and sized to about 4 mm. The facility further did not follow the recipe for the soft and bite size hamburger item. During kitchen observation, Cook1 served minced hamburger meat mixed with melted cheese over crumbly bread to residents on a soft and bite size diet, rather than hamburger chopped into 1/2-inch pieces. Cook1 stated the recipe was not followed and that minced hamburger mixed with cheese was prepared instead of the intended soft and bite size hamburger. The Dietary Supervisor stated cooks should always follow the menu and recipe to ensure the correct texture and recipe were served. The facility’s recipe for Bacon Cheeseburger on a bun specified IDDSI Level 6 tender meat chopped into 1.5 cm by 1.5 cm pieces with a minced and moist bun, and the facility policy required standardized recipes to be maintained and used in food preparation.
Unsafe Dish Sanitizing and Improper Food Storage
Penalty
Summary
Safe and sanitary food storage and preparation practices were not maintained in the kitchen. During observation in the dishwashing area, the dishwasher was rinsing dirty dishes and loading them into the dish machine while a dietary aide removed washed dishes and stored them on shelves. The dietary aide demonstrated the dish machine sanitizer test and the strip showed no sanitizer in range, with the recommended chlorine concentration listed as 50-100 PPM. Although the dishwashing sanitizer log for the same date indicated 50 PPM, the dietary supervisor retested the sanitizer solution three times and verified that it was 0 PPM and not effective in sanitizing dishes. During the same observation, the dietary supervisor started the dishwasher, confirmed the sanitizer was not effective, instructed kitchen staff to remove all washed dishes from storage, and contacted the repair company. The dietary supervisor stated the facility would use disposable plates and utensils. The dietary supervisor also stated the dishes had not been sanitized and could result in cross contamination and make residents sick. The facility's dish machine temperature log stated chlorine should be maintained at 50-100 PPM and that the dietary supervisor should be alerted if temperature or chlorine were not at the correct level. In a separate kitchen observation, a cook used a kitchen towel stored on top of the counter to wipe food preparation counters and then left the towel on the counter. The cook stated the towel should be stored in sanitizer solution when not in use, but said it was disposable and had been forgotten on the counter. Later, one medium container of sliced ham and one container of previously prepared tuna salad were found in the walk-in refrigerator past their use-by dates. The cook stated the tuna salad and ham were generally kept for three days, and the dietary supervisor removed both items and stated they were expired and would be discarded. Facility policy and the refrigerated storage guide required foods to be labeled and stored according to the applicable storage time limits, and the FDA Food Code date-marking guidance for ready-to-eat refrigerated foods was reviewed during the investigation.
Failure to Release Lap Tray Restraint per Care Plan
Penalty
Summary
The facility failed to ensure a resident was free from physical restraint use when a lap tray remained in place on the resident’s wheelchair without documented release every two hours and repositioning as directed in the resident’s restraint care plan and the facility’s restraint policy. The resident had diagnoses including type 2 DM, history of falling, dementia, and adult failure to thrive. The resident’s H&P indicated the resident could make some needs known but could not make medical decisions, and the informed consent for the lap tray was signed by the responsible party. The resident’s MDS indicated the resident sometimes could make herself understood, rarely understood others, had impaired vision, and had restraints that prevented rising from a chair. The physical restraint care plan directed staff to release the lap tray at least every two hours and reposition the resident. The restraint review indicated the lap tray was started for the resident while up in a wheelchair, and a physician order later directed use of the lap tray while on the wheelchair for proper trunk control. During observation, the resident was seen sitting in the activity room in the wheelchair with the lap tray in place. Staff interviews showed the lap tray was used for trunk support and to prevent the resident from falling out of the wheelchair, and staff could not explain whether the restraint was released every two hours. The DON stated the lap tray was a restraint because it restricted freedom of movement, the facility’s restraint policy required motion and exercise for at least 10 minutes during each two-hour period, and the facility did not have documentation showing restraint monitoring or removal for the resident.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to provide care in accordance with professional standards for one sampled resident by not rotating subcutaneous insulin glargine injection sites as ordered. The resident had diagnoses including type 2 DM, dementia, adult failure to thrive, and peritoneal adhesions. The MDS indicated the resident rarely or never could make herself understood and rarely or never had the ability to understand others, and the H&P stated the resident did not have the capacity to understand and make decisions. The physician order for insulin glargine included instructions to rotate injection sites. A review of the Location of Administration Report showed that facility licensed nurses administered insulin glargine in the abdomen right lower quadrant on multiple occasions without rotating the site. During interviews, an LVN, an RN, and the DON acknowledged that the injection sites were not rotated and stated that staff should rotate insulin injection sites to prevent hardening of the skin. The DON also confirmed the facility policy stated injection sites should be rotated, preferably within the same general area.
Failure to Provide Communication Supports for a Resident with Limited English Proficiency
Penalty
Summary
The facility failed to provide proper care and treatment to support the communication abilities of one resident with limited English proficiency and severe cognitive impairment. The resident was admitted with diagnoses including primary open angle glaucoma and unspecified dementia, and the H&P stated the resident did not have the capacity to understand and make decisions. The care plan identified a communication deficit, difficulty making needs known, difficulty understanding others, and a language barrier, with interventions to anticipate needs, use a communication device, and use translation by same-language staff and family. The MDS also indicated the resident needed an interpreter to communicate with a doctor and health care staff. During observation and interview, the resident stated that English was not good enough to understand and then spoke in another language. No communication device, translator availability information, or communication board was observed in the resident's room, and the weekly menu and activity calendar posted there were in English. A CNA stated the resident spoke a different language, could not respond in English, and that staff sometimes used signals or relied on the resident's family member to translate when present. The CNA also stated that otherwise the facility would not know what the resident needed. An RN stated the facility did not have a method of contacting a translator for a resident who did not speak English and that staff used nonverbal cues to communicate. The RN stated she used her own phone and Google Translate to try to understand the resident, and acknowledged she should not be using her own phone. The DON stated the facility did not have a formal translation system, should have one in place, and should not rely on the resident's family. The DON also stated the resident's posted menu and activity materials were all in English and the resident would not be able to understand them.
Incorrect LALM Setting for Resident at Risk for Pressure Injury
Penalty
Summary
The facility failed to set the appropriate setting for a Low Air Loss Mattress for one resident reviewed for pressure ulcers/injuries. The resident was admitted with diagnoses including Alzheimer's disease, unspecified protein-calorie malnutrition, and type 2 diabetes mellitus, and was documented as incapable of participating in the treatment plan and on hospice. The Minimum Data Set indicated severe cognitive impairment, dependence on staff for transfers, risk for pressure ulcers/injuries, and use of a pressure-reducing device for bed. The resident weighed 104 lbs. and had an order allowing the use of a LALM for skin integrity without documented specific settings. During a concurrent observation, interview, and record review, the resident was observed on a Drive LALM set between 0 and 80 lbs. The LVN, RN, and DON each stated the mattress setting was based on resident weight and confirmed the resident's weight was 104 lbs., but the mattress remained set at 0 to 80 lbs. The LVN stated the resident could have developed redness, skin problems, and a pressure ulcer because the mattress was at the wrong setting. The RN stated an incorrect setting would have defeated the purpose of the LALM and could have affected skin integrity, and the DON stated the resident's LALM was not at the correct setting.
Incorrect Cetirizine Dose Administered
Penalty
Summary
The facility failed to administer one of six medications correctly for one sampled resident during a morning medication pass. During an observation, an LVN prepared six medications for the resident, including one tablet of cetirizine 10 mg by mouth. A review of the resident’s medication order showed cetirizine 5 mg, one tablet by mouth two times a day for allergy, indicating the administered dose did not match the ordered dose. During a later interview and observation at the medication cart, the surveyor asked to see the cetirizine bottle for the resident. The LVN produced a bottle labeled cetirizine 10 mg and acknowledged that the resident’s order was for cetirizine 5 mg, stating she made a mistake. The DON stated that adverse reactions for cetirizine included dizziness and that the facility would be monitoring the resident. The facility policy stated medications are to be administered as prescribed and that physician orders are checked for the correct dosage schedule prior to administration.
Kitchen Staff Competency for Sanitizer Testing
Penalty
Summary
The facility failed to ensure that one of three sampled kitchen staff members, Dietary Aide 2, was routinely trained and evaluated for competency related to kitchen duties. During an observation in the kitchen, Dietary Aide 2 was sanitizing dishes in a sanitizer solution made with QUAT sanitizer. When asked to check the sanitizer solution concentration, Dietary Aide 2 first attempted to use the dish machine sanitizer test strip, which is for chlorine sanitizer, instead of the correct test strip for the manual dishwashing sanitizer solution. Dietary Aide 2 stated the test strip was not working, identified the normal range as 100 PPM, and said the color change should be blue. The Dishwasher staff then provided the correct test strip, and Dietary Aide 2 immersed it in the sanitizer solution and counted for 20 seconds to read the result. Dietary Aide 2 also stated that dishes must be submerged in the sanitizer solution for five to ten minutes before being removed to air dry. During interview, the Dietary Supervisor stated Dietary Aide 2 was using the wrong test strip to test the sanitizer solution concentration and that kitchen staff needed to know how to check solutions. The Dietary Supervisor stated that if kitchen staff did not check the sanitizer correctly, the dishes could potentially be contaminated and not sanitized. The Dietary Supervisor also stated that in-services had been provided to staff on sanitizer solutions and how to check for concentration, but did not know whether the annual competency review included sanitizer solution testing. Review of the Dietary Aide job description showed general duties and responsibilities to wash and clean utensils as directed, and the facility's annual dietary competency evaluation did not list manual dishwashing or checking sanitizer concentration for review. The manufacturer procedure for manual pot and pan washing stated to submerge items in the sanitizer sink for one minute or as specified by the product label, and the posted manufacturer recommendation for sanitation range testing stated the solution should be tested at room temperature, dipped for 10 seconds, compared immediately to the package scale, and maintained between 150 and 400 PPM.
Room Size Did Not Meet Minimum Space Requirements
Penalty
Summary
The facility failed to ensure two sampled residents' rooms, room [ROOM NUMBER] and room [ROOM NUMBER], met the minimum space requirements of 80 square feet for each resident. The deficiency was identified during observation, interview, and record review, and the report states this failure had the potential to result in inadequate space to provide safe nursing care and privacy for the residents in those rooms. During an initial observation tour on 3/4/2026, facility staff were observed with enough space to provide care and services to residents in each of the facility's rooms. A review of the facility's room waiver request letter dated 3/6/2026 showed the facility requested a waiver for room [ROOM NUMBER] and room [ROOM NUMBER], stating there was enough space to provide for each resident's care, dignity, and privacy and that the rooms were in accordance with the special needs of the residents. The letter listed room measurements of 102 with 2 beds at 158.35 square feet and 114 with 4 beds at 287 square feet. During interviews, the Director Rehabilitation Services stated most therapy was provided in residents' rooms and there was enough room for therapy in all rooms at the facility, and Resident 89 stated she did not have any issues with the size of room [ROOM NUMBER].
Failure to Implement Comprehensive Care Plan for Resident with Leaf Sensor Device
Penalty
Summary
The facility failed to implement a comprehensive care plan that addressed all of a resident's assessed needs upon admission with a medical device, specifically a Leaf Sensor. The resident was admitted and readmitted with multiple diagnoses, including metabolic encephalopathy, type II diabetes mellitus, actinic keratosis, and rosacea. The resident's Minimum Data Set indicated moderate cognitive impairment and a need for moderate assistance with activities of daily living. The Braden Scale assessment showed a mild risk for pressure ulcers, and the resident was admitted with a Leaf Sensor on the mid-chest, with a physician's order to reinforce the sensor with Tegaderm if it became dislodged. Despite the care plan identifying the presence of the Leaf Sensor and the associated risk for infection and skin breakdown, staff interviews and record reviews revealed that key interventions were not implemented. Certified Nursing Assistants and nursing staff were not adequately informed or trained on the care and purpose of the Leaf Sensor. There was no documentation or evidence that the resident's skin integrity was assessed under the device, nor were pain assessments conducted as required by the care plan. Staff also did not document any reinforcement of the Tegaderm, and the monitoring device associated with the Leaf Sensor was not present in the facility during the resident's stay. The Director of Nursing and Administrator confirmed that there was no specific policy or procedure for the Leaf Sensor device, and that staff relied on general manufacturer guidelines. However, these guidelines required periodic inspection of the skin under the sensor for irritation or infection, which was not performed or documented. The lack of assessment and documentation regarding the resident's skin integrity and pain at the sensor site constituted a failure to follow the comprehensive care plan and physician orders, resulting in a deficiency.
Failure to Assess and Monitor Skin Integrity for Resident with Leaf Sensor Device
Penalty
Summary
The facility failed to follow professional standards of practice in the management, assessment, and monitoring of a resident who was admitted with a Leaf Sensor medical device. The resident, who had multiple diagnoses including metabolic encephalopathy, type II diabetes mellitus, actinic keratosis, and rosacea, was admitted with a Leaf Sensor attached to the mid-chest. The care plan identified the risk of skin breakdown and infection at the sensor site, with specific interventions such as providing good skin care, assessing skin integrity, assessing for pain, and reinforcing the sensor with Tegaderm if dislodged. However, there was no documentation that these interventions were carried out, particularly regarding assessment of skin integrity and pain at the sensor site. Interviews with facility staff revealed a lack of knowledge and training regarding the Leaf Sensor device. The Certified Nursing Assistant reported not being informed about the care required for the sensor, and the Treatment Nurse admitted to never fully assessing the skin underneath the device or being educated on its use. The Director of Nursing confirmed that there was no specific policy for the device and that the manufacturer's guidelines were not fully implemented, as the sensor was never removed or the skin underneath assessed during the resident's stay. Additionally, the monitoring component of the device was not present in the facility, and there was no documentation of reinforcement or assessment as required by the care plan and physician's orders. The facility's policies required licensed nurses to document meaningful and informative notes reflecting care, treatment, and assessments, including skin and pain assessments. The manufacturer's guidelines for the Leaf Sensor also specified the need for periodic inspection of the skin around the sensor for signs of irritation or infection. Despite these requirements, the facility did not document or perform the necessary assessments, placing the resident at risk for skin-related complications associated with the device.
Failure to Implement Care Plans Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide appropriate care and services to a resident diagnosed with dementia, resulting in a fall and injury. The resident, who had a history of falls and was at high risk for further falls, was being transported in a wheelchair by a CNA. The CNA did not provide any instructions or reassurance to the resident during the transport, despite the resident's known episodes of confusion, forgetfulness, and poor safety awareness. The CNA chose a route with multiple steep ramps, which was closer to the street parking for convenience, rather than a safer flat route through the garage. During the transport, the resident became nervous and made a sudden movement while being wheeled up a ramp, causing the wheelchair to tilt and the resident to fall. The CNA attempted to catch the resident but was unsuccessful, resulting in the resident sustaining a right clavicle fracture and severe pain. The facility's staff, including the LVN and CNA involved, did not follow the resident's existing care plans for dementia and fall risk, which required explaining procedures, providing reassurance, and ensuring safety during transport. The facility's failure to implement the resident's care plans and to develop an appropriate care plan for wheelchair transport contributed to the incident. The staff did not assess the resident's comfort with wheelchair use, did not provide necessary instructions to prevent sudden movements, and did not use a safer route or request additional assistance for the transport. These oversights led to the resident's fall and subsequent injury, highlighting deficiencies in the facility's care and safety protocols for residents with dementia.
Failure to Provide Appropriate ROM and Mobility Care
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion (ROM) and mobility for two residents, leading to potential health risks. For Resident 49, the facility did not correctly apply a left knee splint during a Restorative Nursing Aide (RNA) treatment session, as observed on January 28, 2025. The splint was placed too low on the leg, not covering the knee as required, which could exacerbate contractures. Additionally, the RNA order for Resident 49 was incorrect, allowing for the wearing of knee splints for four to six hours, despite physical therapy determining a maximum safe duration of three hours to prevent skin irritation and other adverse effects. Resident 49's medical history includes severe sepsis, muscle wasting, and generalized osteoarthritis, with severe cognitive impairments and functional limitations in the lower extremities. The resident's care plan and physician's orders emphasized the importance of correctly applying splints and adhering to the recommended duration to prevent further decline in ROM. However, the facility's failure to follow these directives was evident during observations and interviews with staff, including the Director of Nursing and Physical Therapist. For Resident 54, the facility did not provide active range of motion (AROM) exercises for both upper and lower extremities as ordered by a physician. Instead, passive range of motion (PROM) exercises were performed, which are not suitable for residents capable of AROM. Resident 54, who has hemiplegia and osteoarthritis, expressed a desire to continue exercises for arms and legs, but the RNA session only included walking and a leg exercise stepper. The failure to perform AROM exercises could lead to a decline in strength and function, contrary to the care plan's goals. Interviews with staff, including the Director of Staff Development and Physical Therapist, confirmed the importance of following AROM orders to maintain the resident's strength and prevent contractures.
Deficient Competency Checks for Restorative Nursing Aides
Penalty
Summary
The facility failed to ensure that annual competencies were completed for six sampled Restorative Nursing Aides (RNAs) who are responsible for tasks such as applying and removing splints and braces. This deficiency was identified through observation, interviews, and record reviews. Specifically, the competency evaluations for RNAs did not include a skills performance check for the application and removal of splints and braces, which are crucial for maintaining residents' range of motion and preventing contractures. During an observation, an RNA incorrectly applied a knee splint on a resident, placing it too low on the leg, which was later corrected by a Physical Therapist. The Director of Staff Development confirmed that the annual competency checklists for RNAs did not include evaluations for splint and brace application, despite the facility's policy requiring such competencies to ensure resident safety. The facility's policy on splint application emphasizes the importance of correct application to prevent contractures and maintain range of motion. The lack of proper competency checks could potentially lead to improper application of splints and braces, as evidenced by the incorrect placement observed during the survey.
Failure to Maintain Electrical Rehabilitation Equipment
Penalty
Summary
The facility failed to maintain six pieces of electrical rehabilitation therapy equipment, which are essential for restoring residents to their highest possible level of physical, mental, and psychosocial well-being. The equipment included upper and lower extremity bicycles, automatic parallel bars, an exercise leg stepper, an adjustable work table, and an adjustable therapy mat. The user manuals for these devices recommended regular maintenance checks, including electrical safety inspections and routine checks for power cord damage. However, the facility did not perform these checks, as confirmed by the Physical Therapist and the Maintenance Director, who stated that maintenance was only performed if issues were reported by therapists. The Administrator and Director of Nursing acknowledged the importance of maintaining the rehabilitation equipment to ensure resident safety and effective therapy. Despite this, the facility lacked a policy for the maintenance of electrical equipment in the rehabilitation department and did not have a user manual for the adjustable work table. The absence of maintenance logs or documentation further highlighted the facility's failure to adhere to the manufacturer's maintenance recommendations, potentially putting residents at risk of injury during therapy sessions.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent accident risks and hazards for a resident, identified as Resident 77, who was admitted with significant medical conditions including hemiplegia, hemiparesis, and severe cognitive impairment. The resident required substantial assistance with daily activities such as toileting hygiene, walking, and transferring between bed and wheelchair. Despite being assessed as a high risk for falls, the resident experienced multiple falls within the facility, including an unwitnessed fall on 1/23/2025. On 1/27/2025, Resident 77 was found sitting on the floor in their room, with the wheelchair nearby and the call light out of reach on the bed. The resident was unable to recall how they ended up on the floor and was not in pain or visibly injured. The Registered Nurse Supervisor confirmed that the resident had fallen from the wheelchair and acknowledged that the resident required assistance with transfers to prevent such incidents. The resident was subsequently assessed by a Nurse Practitioner and transferred to a General Acute Care Hospital for further evaluation. The facility's policy on fall risk and prevention of injury was not adequately followed, as the resident was not provided with the necessary supervision and assistance to prevent falls. The Director of Nursing acknowledged the resident's high risk for falls and the need for frequent monitoring and supervision. Despite the care plan interventions, the lack of adequate supervision and assistance led to the resident's fall, highlighting a deficiency in the facility's implementation of fall prevention measures.
Deficiency in Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen therapy had properly labeled equipment and a physician's order for the therapy. The resident, who was admitted with chronic obstructive pulmonary disease (COPD), cerebral infarction, and nicotine dependence, was observed receiving oxygen via nasal cannula with a pre-filled humidifier that was not labeled. The Licensed Vocational Nurse confirmed the lack of labeling, which is required to ensure proper tracking and maintenance of the equipment. Further review revealed that there was no physician's order for the resident's oxygen therapy, which is necessary for residents with COPD to ensure appropriate care parameters are followed. The Director of Nursing acknowledged that the standing order for oxygen was missed upon the resident's admission, and the lack of a physician's order meant that nurses could not administer the required oxygen. The facility's policies require a physician's order for oxygen administration and proper labeling of equipment, which were not adhered to in this case.
Incomplete Documentation of Knee Splint Usage for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate documentation for Resident 49, specifically regarding the tolerance of knee splints. Resident 49, who was admitted with severe sepsis, muscle wasting, and generalized osteoarthritis, had a care plan that included the use of knee splints to prevent contractures. The physician's order required the splints to be worn for four to six hours daily, as tolerated. However, the RNA flowsheet for January 2025 did not document the duration for which the knee splints were worn from January 1 to January 27, 2025. During an observation on January 28, 2025, RNA 1 was unable to find the knee splints and did not apply them to Resident 49. RNA 1 later acknowledged that on January 27, 2025, Resident 49 tolerated the splints for only two hours, but this was not documented. RNA 1 admitted that there were other days when the resident could only tolerate the splints for two hours, but these instances were not recorded, leading to incomplete documentation. Interviews with the Physical Therapist and the Director of Staff Development confirmed that the RNA documentation was incomplete and did not reflect the actual duration the splints were worn. The Director of Nursing emphasized the importance of following RNA orders and maintaining accurate documentation to reflect the resident's condition during RNA treatment. The facility's policy on documentation principles required that health records be current, accurate, and descriptive, which was not adhered to in this case.
Deficiency in Room Space Requirements
Penalty
Summary
The facility failed to ensure that two of the sampled resident rooms met the minimum space requirements of 80 square feet per resident in multiple resident bedrooms. Specifically, room 102, which housed two residents, measured 158.35 square feet, and room 125, which housed three residents, measured 229.54 square feet. These measurements fell short of the required 160 square feet for a two-bedroom and 240 square feet for a three-bedroom. Despite this, the facility submitted a letter to the Department requesting a room variance, stating that the rooms had adequate space for the residents and would not adversely affect their health and safety or impede their well-being. During observations and interviews, nursing staff and residents expressed that the space in these rooms did not interfere with care or comfort. Licensed Vocational Nurse 1 and Certified Nursing Assistant 1 both reported that the space was not an issue and did not hinder their ability to provide care. Residents in the rooms also stated they had no complaints about the space, and staff were able to assist them without difficulty. Despite these observations, the facility's failure to meet the minimum space requirements was noted as a deficiency.
Inaccurate Resident Assessment of Fall History and ROM
Penalty
Summary
The facility failed to ensure an accurate comprehensive assessment for a resident, which did not reflect the resident's history of falls and functional limitations in range of motion (ROM). The resident was admitted with a history of repeated falls and a displaced comminuted fracture of the right femur, and was later readmitted with a periprosthetic fracture around the internal prosthetic right hip joint. Despite these conditions, the Minimum Data Set (MDS) inaccurately indicated that the resident had no falls in the last month and no fractures related to falls in the last six months prior to admission. Additionally, the MDS incorrectly noted no impairment in the lower extremity ROM. Interviews with the MDS coordinator and the Director of Nursing (DON) confirmed the discrepancies in the resident's MDS assessment. Both acknowledged that the fall history and functional limitation in ROM were inaccurately documented. The MDS coordinator and the DON emphasized the importance of accurate assessments to prevent potential risks of injury or falls. The facility's job description for the Resident Assessment/Care Plan Coordinator (MDS) outlines the responsibility for ensuring accurate resident assessments in accordance with current regulations.
Failure to Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with a history of falls, as per the Interdisciplinary Team (IDT) plan, which required a sitter from 3 PM to 7 AM. The resident, who had severe cognitive impairment and was at high risk for falls, was observed alone in their room without a staff member present. This occurred when the assigned Certified Nursing Assistant (CNA) left the room to dispose of trash without notifying another staff member to take over supervision. The CNA acknowledged the need for continuous supervision and admitted to not informing other staff members of their temporary absence. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the CNA should have communicated their need to leave the room and ensured another staff member was present. The DON also noted that the fall care plan was not updated to reflect the IDT's decision for a sitter, which was crucial for staff awareness and intervention implementation. The facility lacked a specific policy for sitters or one-to-one supervision, which contributed to the oversight in maintaining the resident's safety.
Delayed Response to Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to promptly assess and address a change in condition for a resident who exhibited symptoms of chest congestion and a productive cough. The resident, who had a complex medical history including a heart transplant, immunodeficiency, and quadriplegia, was not immediately assessed by the Licensed Vocational Nurse (LVN) when the change in condition was reported by a Certified Nursing Assistant (CNA). The LVN did not check the resident's vital signs or inform the Registered Nurse (RN) on duty about the change in condition in a timely manner. The RN also failed to perform a thorough assessment of the resident's condition, including checking vital signs and performing chest auscultation, after being informed by the LVN. Furthermore, the RN did not notify a medical doctor or nurse practitioner about the resident's condition, which included a productive cough and chest congestion. This lack of immediate action and communication resulted in a significant delay in providing necessary medical services to the resident. As a result of these deficiencies, there was a delay of over seven hours in addressing the resident's medical needs. The resident was eventually found unresponsive and was transferred to a general acute care hospital, where they were diagnosed with septic shock, severe dehydration, and other complications. The resident passed away two days after the transfer, highlighting the critical impact of the facility's failure to promptly assess and respond to the resident's change in condition.
Failure to Respect Resident's Dignity During Care
Penalty
Summary
The facility failed to provide care that promoted or enhanced the dignity and respect of a resident, identified as Resident 1, who was admitted with multiple sclerosis, right hand contracture, and dementia. The resident had fluctuating capacity to understand and make decisions, as noted in their history and physical assessment. Despite having intact cognition for daily decision-making, Resident 1 required maximal assistance from staff for activities of daily living (ADLs). On a specific occasion, Resident 1 resisted care and became combative during ADL assistance, specifically when being changed and cleaned. During an interview, a Certified Nursing Assistant (CNA1) reported that they continued to assist Resident 1 despite the resident's combativeness, as they could not find additional help at the time. The Director of Nursing (DON) later stated that staff should stop providing care if a resident becomes resistive and combative to prevent injury. The facility's policy emphasizes treating residents with consideration, respect, and dignity, which was not adhered to in this instance, potentially causing psychosocial harm to Resident 1.
Failure to Notify Physician and Document Change of Condition
Penalty
Summary
The facility staff failed to ensure proper physician notification and documentation of a change of condition for a resident. The resident, who was admitted with diagnoses including multiple sclerosis, right hand contracture, and dementia, exhibited multiple scattered skin discolorations on the upper extremities and had an episode of resisting care with combativeness during activities of daily living. Despite these changes, there was no documentation of a change of condition using the SBAR tool, nor was the physician notified as required by the facility's policy. Interviews with staff revealed that a Certified Nursing Assistant (CNA) did not report the resident's refusal of care and combativeness immediately, as he went on a lunch break. The Registered Nurse (RN) and Licensed Vocational Nurse (LVN) were only informed after the CNA returned, and there was uncertainty about whether the physician was notified or if a change of condition was documented. The Treatment Nurse confirmed that no skin discolorations were documented prior to the resident's transfer to a general acute hospital, and the Director of Nursing emphasized the importance of immediate reporting and documentation for any new skin issues or behavioral changes.
Failure to Document Grievance
Penalty
Summary
The facility failed to ensure documentation of grievances was completed for one of three sampled residents. Resident 1 was admitted with diagnoses including cerebral infarction, difficulty in walking, and abnormal posture. The Minimum Data Set indicated that Resident 1 had severely impaired cognitive skills and required moderate assistance for activities of daily living. Despite these needs, a grievance reported by Resident 1's family member on 4/17/2024 was not documented. The family member found Resident 1 in a wheelchair with no undergarments and pants below the knee and reported this to the head nurse. The Registered Nurse notified the Director of Nursing and the Director of Staff Development about the concern, but no grievance report was completed because the family member refused to discuss the issue further with the Director of Staff Development. The Director of Nursing acknowledged the importance of documenting grievances to investigate and resolve issues but admitted that a grievance report should have been completed in this case. The facility's policy and procedures, reviewed on 1/9/2024, state that the resident has the right to have grievances promptly addressed. The failure to document the grievance violated Resident 1's family's right to have their concern addressed, as per the facility's grievance policy.
Failure to Document Medication Intolerance
Penalty
Summary
The facility failed to document a medication intolerance for cephalexin in the medication allergy profile of a resident, leading to the resident receiving the medication again and experiencing adverse effects. The resident, who had severe cognitive impairment and required moderate assistance for activities of daily living, was initially prescribed cephalexin for a urinary tract infection. After the first dose, the resident experienced nausea and vomiting, but this intolerance was not documented in the allergy profile. Consequently, the resident was prescribed and administered cephalexin again, resulting in another episode of nausea and vomiting. The Director of Nursing acknowledged the oversight and stated that if the allergy had been documented, the medication would not have been administered a second time. The resident's physician was also unaware of the initial adverse reaction and stated that he would not have prescribed cephalexin again if the allergy had been documented. The facility's policies on medication administration and orders emphasize the importance of documenting allergies and verifying orders, but these protocols were not followed in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beverly Hills Rehabilitation Centre | 0.6 mi | ★★★★★ | 3 | 0 |
| Miracle Mile Healthcare Center, Llc | 0.6 mi | ★★★★★ | 46 | 0 |
| Sharon Care Center | 0.7 mi | ★★★★★ | 57 | 0 |
| Kennedy Care Center | 1.1 mi | ★★★★★ | 12 | 0 |
| West Pico Terrace Healthcare & Wellness Centre Lp | 1.1 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.