Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Angels Care Center during CMS and state inspections, most recent first.
A resident with dementia, recent hip fracture aftercare, and frequent urinary incontinence did not receive a complete bowel and bladder assessment or an individualized incontinence care plan. Key sections of the incontinence assessment, such as symptoms, onset and pattern, contributing physical and cognitive factors, medications, and type of incontinence, were left blank. The care plan only addressed assistance with transfers and toileting, without specific urinary incontinence goals or interventions, and the NA care sheet and Kardex lacked continence status and a toileting plan. Staff reported relying on a general practice of offering toileting or checking for incontinence every 2–3 hours, while the DON acknowledged the incomplete assessment and missing urinary incontinence care planning despite a policy requiring comprehensive, individualized bowel and bladder programs.
Three cognitively intact residents did not receive timely assistance with toileting and personal care because staff turned off call lights without providing the requested help. This resulted in two residents soiling themselves and another, who was non-weight bearing, attempting to transfer herself to the bathroom. Staff interviews revealed a practice of turning off call lights to keep response times low, but sometimes failing to return, contrary to facility policy and residents' care plans.
A resident with multiple respiratory diagnoses was not consistently offered their ordered CPAP therapy after a room transfer, and staff documented CPAP care as completed even when the device was not present. The provider was not notified of the resident's repeated refusals to use the CPAP, despite care plan instructions and facility expectations.
The facility failed to implement effective infection control measures, leading to outbreaks of Influenza A and Norovirus. Residents with symptoms were not isolated promptly, and staff did not consistently use PPE or perform hand hygiene. Symptomatic employees continued working, and the dishwasher did not reach sanitizing temperatures, exacerbating the spread of infections among residents, including those with underlying health conditions.
The facility failed to consistently monitor and document dishwasher temperatures, risking inadequate sanitization of dishware. Staff were unaware of procedures to ensure temperatures met required levels, and numerous instances of unrecorded or insufficient temperatures were found. This posed a risk to infection control, especially given the presence of Covid and influenza in the facility.
A facility failed to provide necessary assistance with eating for four residents with cognitive and physical impairments. These residents were left unattended for 20 minutes during breakfast, with food served but not consumed due to lack of staff support. Interviews revealed a lack of coordination, and the facility's policy on meal assistance was not followed.
A facility failed to maintain food at a steady temperature greater than 140°F for four residents during breakfast. The residents, who required assistance with eating due to cognitive impairments, were left unattended with meals served at temperatures below the required level, affecting food palatability. Staff acknowledged the deficiency, noting that meals should not have been served without available assistance.
A resident with moderate cognitive impairment and multiple health conditions was not assisted with personal grooming, specifically shaving facial whiskers, compromising their dignity. Despite the resident's indication of wanting assistance, staff did not initially fulfill this need, and the care plan lacked specific instructions for personal hygiene. The clinical manager was unaware of the issue, which should have been addressed during routine care.
A facility failed to accurately code the MDS for a resident receiving hospice care, as the quarterly MDS did not reflect hospice services in Section O. The resident had been admitted to hospice services, but this was not documented in the MDS. The director of reimbursement and MDS coordinator confirmed the omission as a coding error, and the DON stressed the importance of MDS accuracy. The facility lacked a specific MDS policy, relying on the RAI manual.
A facility failed to administer bowel management medications per physician's order for a resident with a history of neuromyelitis optica and other conditions. Despite orders for senna-docusate sodium to prevent constipation, the resident had not had a bowel movement in six days. Interviews revealed that the facility's standing orders for bowel management were not followed, and the resident did not receive PRN medications as required.
A resident with mobility impairments was found without access to their call light, which was essential for communicating needs to staff. The resident, who was non-ambulatory and dependent on staff for mobility, was observed in a wheelchair with the call light out of reach. Staff interviews confirmed the resident's dependency on the call light, and the facility's policy required staff to ensure call lights were accessible, which was not followed in this instance.
A resident with a known shellfish allergy was served shrimp pasta salad, leading to a severe allergic reaction and hospitalization. Despite the dietary aide preparing the correct meal, the nursing assistant delivered the wrong tray. The resident was treated with epinephrine and transported to the ICU. The facility's investigation into the incident was inconclusive.
A resident with a history of falls and cognitive impairment was left unattended in the bathroom by a nurse aide, contrary to her care plan. This resulted in the resident attempting to self-transfer, leading to a fall and a right femur fracture requiring surgery. Staff interviews and observations indicated a lack of adherence to care plan interventions and insufficient staff education on the resident's needs.
The facility failed to ensure accurate documentation of advanced directives for two residents, leading to potential errors in administering life-saving treatments. One resident would have been denied CPR contrary to their wishes, while another would have received CPR against their wishes. Staff inconsistencies in checking code status between the EHR and hard chart contributed to the deficiency.
A resident was observed self-administering a nebulizer treatment without a proper assessment or provider order. The resident, who was cognitively intact, stated that staff did not observe him during the treatment. The LPN and DON confirmed the absence of an assessment or provider order in the medical record, and the facility's policy on self-administration of medications was not provided.
The facility failed to implement and maintain the recommended restorative programming for a resident with hemiplegia and contracture of the left hand. The resident's care plan included passive range of motion (PROM) exercises, but the treatment administration record lacked documentation of completion or refusals. Observations and interviews revealed that the resident was not regularly offered PROM exercises, and there was no documentation of refusals in the electronic health record.
The facility failed to ensure post-dialysis assessment and monitoring for a resident with end-stage renal disease. The resident's care plan and medical records lacked instructions and documentation for monitoring the dialysis shunt for bruit and thrill, despite the facility's policy requiring daily checks. Interviews with staff confirmed the oversight.
A resident reported physical abuse and derogatory remarks by staff, but the facility failed to suspend the accused staff members during the investigation, contrary to its abuse prevention policy.
Failure to Complete Bowel/Bladder Assessment and Individualized Incontinence Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive bowel and bladder assessment and to develop an individualized urinary incontinence care plan for one resident. The resident had diagnoses including surgical aftercare for a right hip fracture, type 2 diabetes, repeated falls, and dementia, and an admission MDS showing moderate cognitive impairment and frequent urinary incontinence requiring maximum assistance for transfers and toileting hygiene. Although the urinary incontinence care area assessment indicated that urinary incontinence would be addressed in the care plan, the bowel and bladder incontinence assessment left multiple sections blank, including incontinence symptoms, onset and pattern of incontinence, bowel movement pattern, relevant physical factors, cognitive/emotional/communication status, medications affecting incontinence, overflow incontinence, physician order for post-void residual, types of incontinence, and care plan review. The resident’s care plan addressed transfer and toileting assistance but did not include urinary incontinence goals or interventions to maintain or improve continence, and the nursing assistant care sheet contained no bowel and bladder information. Documentation from the review period showed the resident was incontinent of bladder fifty-one times and continent ten times, yet there was no individualized urinary toileting plan on the Kardex or NA care sheet. Observations found the resident in a wheelchair with a call light within reach, wearing an incontinence product and stating he needed staff assistance to use the bathroom and disliked being wet, and that he used the call light for toileting or changing. Interviews with an LPN and multiple NAs revealed that toileting information was expected to be on the Kardex or NA care sheet, but for this resident it did not indicate continence status or a urinary toileting plan; staff instead followed a general practice of offering toileting or checking for incontinence every two to three hours. The DON confirmed that the comprehensive bladder assessment for this resident was incomplete and that the care plan did not address urinary incontinence or include a urinary toileting plan, despite a facility policy requiring a comprehensive bowel and bladder assessment on admission, ongoing reassessment, and use of findings to develop an individualized bowel and bladder program and care plan with specific toileting schedules and related interventions.
Failure to Provide Dignified Care Due to Inadequate Call Light Response
Penalty
Summary
The facility failed to provide a dignified living existence for three residents by not ensuring that call lights were used appropriately to meet residents' needs. Staff responded to call lights in a timely manner but would turn off the call lights without providing the requested assistance, resulting in residents not receiving necessary help with toileting and personal care. This led to two residents soiling themselves and another resident, who was non-weight bearing, attempting to transfer herself to the bathroom, contrary to her care plan and safety instructions. One resident, who was cognitively intact and required substantial assistance with toileting due to multiple medical conditions including diabetes, morbid obesity, and lymphedema, reported that her call light was answered and turned off without assistance being provided, causing her to soil herself and develop a macerated area on her skin. Another resident, also cognitively intact and with a non-weight bearing status due to a hip fracture, reported having to self-transfer to the toilet because staff would answer the call light but not return to assist her, despite being instructed not to bear weight or transfer independently. A third resident, with a history of cancer and chronic illness, reported soiling herself while waiting for staff to return after answering her call light, resulting in soiled clothing and discomfort. Interviews with staff revealed that some nursing assistants would turn off call lights upon entering the room to keep response times low, with the intention of returning later, but sometimes forgot to return. The nurse manager and DON were not aware of this practice and stated that the facility's policy was to not turn off the call light until the resident's needs were met. The facility's dignity policy emphasized care that promotes well-being and self-worth, which was not upheld in these instances.
Failure to Follow Physician Orders and Notify Provider for CPAP Refusals
Penalty
Summary
The facility failed to follow physician orders and ensure provider notification regarding a resident's refusals for continuous positive airway pressure (CPAP) therapy. The resident, who had diagnoses including pulmonary fibrosis, acute and chronic respiratory failure, COPD, and obstructive sleep apnea, had physician orders for nightly CPAP use with documentation of hours worn and refusals. Despite these orders, staff documented CPAP use and refusals in the medication and treatment administration records, but on multiple occasions, the CPAP was not present in the resident's room after a room transfer, and the resident was not offered the device as required. Staff also failed to notify the provider of the resident's consistent refusals to use the CPAP, as confirmed by interviews with nursing staff and the nurse practitioner, who was unaware of the refusals. Additionally, the resident's care plan identified behaviors such as agitation and refusal of care, with instructions for staff to encourage CPAP use and notify the charge nurse of refusals. However, during the resident's transfer to a new room, the CPAP was not moved, and staff did not ensure its availability or offer it to the resident. Documentation in the records indicated completion of CPAP care even when the device was not present. The facility was unable to provide a policy regarding refusal of physician orders and provider notification when requested.
Inadequate Infection Control Measures Lead to Outbreaks
Penalty
Summary
The facility failed to implement effective infection control strategies to prevent the spread of Influenza A and Norovirus. This deficiency was observed when the facility did not apply appropriate transmission-based precautions for residents exhibiting symptoms of these infections. For instance, a resident with Influenza A symptoms was not placed under isolation immediately, and precautionary measures were delayed. Additionally, staff members were observed entering rooms of infected residents without donning the necessary personal protective equipment (PPE) and failed to perform hand hygiene, contributing to the spread of infections. The report highlights that the facility did not restrict employees displaying symptoms of Norovirus from working, contrary to CDC guidelines. This oversight allowed symptomatic staff to continue working, increasing the risk of spreading the virus to residents and other staff members. The facility also failed to ensure that the dishwasher reached the necessary temperature to sanitize dishes during the Norovirus outbreak, further compromising infection control measures. Several residents, including those with underlying health conditions such as dementia, hypertension, and chronic kidney disease, were affected by the outbreaks. The facility's lack of timely response and inadequate infection control practices led to a widespread outbreak, placing all residents at risk of serious illness. The report indicates that the facility did not conduct active surveillance for influenza illness among residents and staff, which is a critical component of outbreak management in long-term care settings.
Dishwasher Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, which had the potential to affect all 108 current residents and staff who consumed food served from dishes cleaned in the dishwasher. During an observation, it was noted that the temperatures for the morning cycle had not been logged, and the dietary aide was unaware of the need to ensure the dishwasher reached the desired temperatures before starting the dishwashing process. The certified dietary manager confirmed that staff were not aware of the procedure to run two or more racks through to bring the temperatures up to the desired levels prior to starting the dishwashing cycle. A review of the dishwasher temperature logs revealed numerous instances where the wash and rinse temperatures were below the required levels. Specifically, the wash temperature was below the desired range on 36 occasions, and the rinse temperature was below the desired range on 10 occasions during the period reviewed. Additionally, there were significant gaps in documentation, with 48 incidents of unrecorded wash temperatures and 49 occasions of unrecorded rinse temperatures. The facility's policy on dishwasher temperature monitoring lacked specific instructions for staff to run multiple racks to achieve the desired temperatures and to record the temperatures on the logs. The service representative confirmed that the required temperatures for washing and rinsing were not consistently met, emphasizing the importance of reaching these temperatures to ensure proper sanitization and prevent illness. Despite the presence of Covid and influenza in the facility, there was no indication that the dishwasher's temperature issues had directly resulted in illness among residents. However, the facility had previously experienced cases of Norovirus, and disposable items were used for meals in certain situations to reduce contact and potential cross-contamination. The facility's failure to maintain and document proper dishwasher temperatures posed a risk of inadequate sanitization of dishware, potentially compromising infection control measures.
Failure to Assist Residents with Meals
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically eating, for four residents who required varying levels of help. These residents, who had significant cognitive and physical impairments, were left without assistance during a meal service. The residents included one with severe cognitive impairment and total dependence on staff for eating, another with severe cognitive impairment requiring partial assistance, a third with moderate cognitive impairment needing substantial assistance, and a fourth with severe cognitive impairment requiring supervision or touching assistance. On the morning of the incident, the residents were served breakfast but were left unattended for 20 minutes without staff assistance. During this time, the food remained uncovered and was not consumed by the residents, as they were unable to eat without help. Observations noted that only two staff members were present in the dining room, assisting other residents, leaving these four residents without the necessary support. The food was eventually replaced with fresh trays after the initial meals had been left out for an extended period. Interviews with staff, including registered nurses and dietary personnel, revealed a lack of coordination and communication regarding meal service and assistance. Staff acknowledged the importance of having personnel available to assist residents before serving meals, as serving cold food could negatively impact residents' quality of life. The facility's policy on meal assistance was not followed, as it directed that residents requiring help should receive it in a manner that meets their individual needs, ensuring safety, comfort, and dignity.
Failure to Maintain Food Temperature for Residents
Penalty
Summary
The facility failed to ensure that food was held at a steady temperature greater than 140 degrees Fahrenheit for four residents during the dining process. The deficiency was observed when residents were served breakfast without staff available to assist them, resulting in the food sitting uncovered and cooling down to temperatures below the required level for palatability. The food items, including cooked cereal, pureed eggs, scrambled eggs, French toast sticks, and sausage, were served at temperatures ranging from 76 to 123 degrees Fahrenheit, which was below the facility's policy requirement of 135 degrees Fahrenheit. The residents involved in this deficiency had various medical conditions that required assistance with eating. One resident had severe cognitive impairment and was totally dependent on staff for eating assistance. Another resident had moderate cognitive impairment and required substantial assistance with eating. The other two residents also had severe cognitive impairments and required assistance or supervision during meals. Despite these needs, the residents were left unattended with their meals, which were not at the appropriate temperature, affecting the quality and palatability of the food. Staff interviews revealed that it was the expectation that staff should be present to assist residents before meals were served. However, on the day of the observation, there were only two staff members available in the dining room, and they were assisting residents at a neighboring table. The food production manager and other staff acknowledged that the food temperatures were not adequate and that the meals should not have been served until staff were available to assist the residents. The facility's policy on food temperature and time requirements was not adhered to, leading to this deficiency.
Failure to Assist Resident with Personal Grooming
Penalty
Summary
The facility failed to assist a resident with personal grooming, specifically shaving facial whiskers, which compromised the resident's dignity and self-determination. The resident, who has a moderate cognitive impairment and is fully dependent on staff for personal hygiene due to conditions such as cerebral palsy, dementia, and multiple sclerosis, was observed with noticeable facial whiskers. Despite the resident's non-verbal indication of wanting assistance with shaving, the staff did not initially fulfill this need. The care plan for the resident lacked specific instructions regarding personal hygiene, and the staff did not address the resident's grooming needs during routine care. The clinical manager was unaware of the resident's grooming issue and acknowledged that it should have been addressed during regular care routines. The facility's policy emphasizes the importance of grooming residents according to their wishes to maintain their dignity, which was not adhered to in this instance.
MDS Coding Error for Hospice Services
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) for a resident, identified as R15, who was receiving hospice care. The quarterly MDS for R15 did not reflect the hospice services in Section O, which is designated for Special Treatments, Procedures, and Programs. R15 had been admitted to hospice services on March 22, 2024, as confirmed by the census report printed on January 24, 2025. During interviews, the director of reimbursement and MDS coordinator acknowledged the omission as a coding error, and the director of nursing emphasized the importance of MDS accuracy to reflect resident care needs. Additionally, the regional clinical director noted that the facility lacked a specific policy on MDS, relying instead on the RAI manual for guidance.
Failure to Administer Bowel Management Medications Per Physician's Order
Penalty
Summary
The facility failed to ensure medications were administered per physician's order for a resident reviewed for bowel management. The resident, who had intact cognition and required assistance with most activities of daily living, had a history of neuromyelitis optica, hypertension, multi-drug-resistant organism, paraplegia, malnutrition, cutaneous abscess of the buttock, and osteomyelitis. The resident's electronic medication record indicated an order for senna-docusate sodium to prevent constipation, but the bowel record showed the resident had not had a bowel movement in six days. Despite the facility's standing orders for bowel management, which included administering PRN medications and performing rectal checks, there was no evidence that these protocols were followed for the resident. Interviews with the resident and nursing staff revealed that the resident was constipated due to pain medication and had not received any PRN medications since the last recorded bowel movement. The nursing staff confirmed that the facility's standing orders for bowel management were not initiated as expected, despite the resident's increased risk for constipation due to pain medication. The facility's bowel management policy required monitoring and implementing PRN medications, but this was not adhered to, leading to the deficiency.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident, identified as R4, had access to their call light, which is essential for communicating needs to the staff. R4, who was cognitively intact but had lower extremity impairments and was non-ambulatory, was observed without access to their call light. The call light was found on the bottom right-hand corner of the bed, out of reach for R4, who was seated in a wheelchair facing away from the door. R4 expressed that this was a recurring issue, as they were unable to self-propel in the wheelchair and relied on staff for mobility assistance. Interviews with various staff members, including a nursing assistant, an LPN, and an RN, confirmed that R4 was dependent on staff for mobility and used the call light to communicate needs. The staff acknowledged that R4 did not have access to the call light during the observation. The facility's policy required staff to ensure call lights were accessible to residents, but this was not adhered to in R4's case. The director of nursing stated that staff were expected to ensure residents had access to their call lights before leaving the room.
Failure to Provide Allergen-Free Meal Results in Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident with a known shellfish allergy received the appropriate meal tray, resulting in the resident consuming shrimp pasta salad. This incident occurred shortly after the resident's admission to the facility. The resident's care plan and meal tray ticket both indicated a shellfish allergy, yet the resident was served a meal containing shrimp. After consuming the meal, the resident experienced severe allergic reactions, including sweating, nausea, stomach pain, and difficulty breathing. The nursing assistant who served the meal tray stated that the meal ticket did not indicate any allergies, although the dietary aide and director of dining confirmed that the meal ticket did list the shellfish allergy. The dietary aide had prepared the tray correctly, substituting the shrimp pasta with a sandwich, as directed by the cook. However, the nursing assistant delivered the incorrect tray to the resident, leading to the allergic reaction. The resident was promptly assessed by an LPN who administered epinephrine and oxygen and called 911. The resident was then transported to the hospital and admitted to the ICU. Interviews with staff revealed inconsistencies in the handling and delivery of meal trays, and the facility's internal investigation was inconclusive regarding how the error occurred.
Failure to Provide Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide care-planned supervision to prevent falls for a resident, resulting in an immediate jeopardy situation. The resident, who had a history of falls and required substantial assistance for toileting and transfers, was left unattended in the bathroom by a nurse aide. This led to the resident attempting to self-transfer, resulting in a fall that caused a right femur fracture requiring surgical intervention. The resident's care plan clearly indicated that staff should not leave her alone in the bathroom due to her high fall risk. The resident had multiple medical conditions, including hypertension, atrial fibrillation, renal failure, and a history of falls. She was cognitively impaired, as indicated by a SLUMS score of 19/30, and had functional limitations in mobility. Despite these risks, the nurse aide left the resident alone in the bathroom, contrary to the care plan instructions. The resident attempted to stand up from the toilet, fell, and sustained significant injuries, including a right hip fracture and multiple skin tears. Interviews and observations revealed that staff were not consistently following the care plan interventions for the resident. Some staff members were unaware of the requirement to stay with the resident in the bathroom, and others failed to review the Kardex or care plan before providing care. The facility's investigation confirmed that the care plan was up-to-date, but staff education on the resident's specific needs was lacking, contributing to the incident.
Removal Plan
- All nursing staff on duty will be trained on the current Kardex/Care Plan and interventions for R1.
- All nursing staff not on duty will be trained at the start of their next shift, prior to beginning duties on unit.
- All nursing staff on duty will be trained on the procedures for Kardex/care plans with emphasis placed on the need to regularly and comprehensively review these documents to ensure that appropriate care is provided.
- Nursing staff not on duty will be trained on the same at the start of their next shift, prior to beginning duties on the unit.
- The policy and procedure for resident care plans has been reviewed/revised.
- The facility had a plan in place and check off system to assure all staff would be educated prior to working their next shift.
Failure to Ensure Accurate Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure that advanced directives were accurately documented on the residents' electronic health records (EHR) and Physician's Orders for Life Sustaining Treatment (POLST). This deficiency affected two residents, one of whom would have been denied cardiopulmonary resuscitation (CPR) contrary to their wishes, while the other would have received CPR against their wishes. The discrepancy between the EHR and the hard chart led to confusion among staff regarding the correct code status for these residents, which could have resulted in inappropriate life-saving measures being administered or withheld during an emergency situation. Resident 24, who had severe cognitive impairment due to dementia and a stroke, was identified as full code in the EHR but had a POLST indicating do not resuscitate (DNR) status. Similarly, Resident 79, who had severe cognitive impairment and Alzheimer's Disease, was identified as DNR in the EHR but had a POLST in the hard chart indicating full code status. Interviews with various staff members revealed inconsistent practices in checking the code status, with some relying on the EHR banner and others on the hard chart, leading to potential errors in emergency situations. The facility's policies required staff to refer to the POLST form for the resident's wishes regarding life-sustaining treatment. However, the discrepancies between the EHR and the hard chart, along with the inconsistent practices among staff, highlighted a significant risk of administering incorrect life-saving treatments. The facility's failure to ensure accurate documentation and consistent practices for verifying code status resulted in an immediate jeopardy situation for the affected residents.
Removal Plan
- The facility completed an audit of all residents' code status.
- The facility reviewed the policy regarding code status and updated the policy, which outlined where the staff would locate the code status.
- Oncoming licensed staff were educated regarding the updated POLST procedure and where to find a residents' code status.
- Education continued for staff.
Failure to Assess Resident for Self-Administration of Nebulizer Treatment
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer nebulizer treatments. The resident, who was cognitively intact according to the Minimum Data Set (MDS) dated 4/9/24, was observed self-administering a nebulizer treatment without a proper assessment or provider order. The resident's self-administration of medication evaluation dated 4/8/24 indicated that the resident did not self-administer medications, including nebulizer medications, after nurse setup. However, the resident's order summary report dated 4/11/24 directed staff to administer albuterol sulfate via nebulizer four times daily, but did not include a provider order for self-administration. During an interview, the resident stated that staff did not observe him while he administered the Albuterol nebulizer. Observations on 4/11/24 confirmed that the resident was self-administering the nebulizer treatment in his room without staff supervision. The LPN and DON both confirmed that there was no assessment or provider order in the resident's medical record to allow for self-administration of the nebulizer treatment. The facility's policy on self-administration of medications was requested but not provided.
Failure to Implement and Maintain Recommended Restorative Programming
Penalty
Summary
The facility failed to implement and maintain the recommended restorative programming for a resident (R71) who had a diagnosis of hemiplegia following a stroke and contracture of the left hand. The occupational therapy (OT) discharge summary recommended a range of motion (ROM) program to decrease the risk of increased tightness, and the care plan instructed staff to complete passive range of motion (PROM) exercises to the left upper extremity (LUE). However, the treatment administration record (TAR) lacked documented evidence of completion or resident refusals to complete the PROM exercises. Observations and interviews with the resident and staff revealed that the resident was not being offered PROM exercises regularly, and there was no documentation of refusals in the electronic health record (EHR). The clinical manager confirmed that the therapy recommendation had been entered as 'prn' (as needed) instead of a scheduled frequency, which led to the lack of documentation and completion of the PROM exercises. Interviews with the licensed practical nurse (LPN) and registered nurse (RN) indicated that the resident should be offered PROM exercises but sometimes refused them. However, these refusals were not documented in the EHR. The occupational therapist and Rehab Director confirmed that the PROM was recommended and ordered at a specific frequency and should not have been entered as 'prn'. The Director of Nursing (DON) stated that therapy restorative program recommendations were given to the nursing clinical managers to update resident care plans and enter the recommendations into the EHR. The DON could not confirm if the PROM was being completed or attempted and refused, as it was not documented in the TAR. The facility policy on therapy rehabilitation referrals indicated that therapy staff would routinely screen all long-term care residents to determine if they might benefit from therapy interventions, but this was not effectively implemented for R71.
Failure to Ensure Post-Dialysis Monitoring
Penalty
Summary
The facility failed to ensure post-dialysis assessment and monitoring for a resident who required such services. The resident, who had intact cognition and required partial assistance with ADLs, had diagnoses including end-stage renal disease and received dialysis treatment outside the facility. The resident's care plan lacked pre- and post-dialysis instructions for monitoring the access site for shunt bruit and thrill. Additionally, the Medication Administration Record and medical record lacked evidence of monitoring the shunt for bruit and thrill. Interviews with the resident and staff confirmed that the resident did not have an order for such monitoring, despite the importance of ensuring the shunt's patency to prevent closure. The facility's policy indicated that residents with an internal shunt should have daily checks of shunt patency by auscultating and palpating for pulse, thrill, and bruit. However, the staff did not follow this policy for the resident in question. The Director of Nursing stated that the expectation was for staff to complete fluid monitoring, vital sign monitoring, and observation of the site, including checking for bruit and thrill, but this was not done for the resident. The clinical manager and licensed practical nurses confirmed the lack of orders and documentation for monitoring the shunt, highlighting a significant oversight in the resident's care plan and daily monitoring practices.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to ensure resident protection pending an investigation into an allegation of abuse. A resident, who was admitted with a diagnosis of anxiety and had intact cognition, reported being physically abused by staff. The resident alleged that a nurse attempted to grab his phone, causing scratches on his forearm, and that a nursing assistant called him derogatory names. Despite the resident's report and visible scratch marks, the facility did not remove the accused staff members from their duties during the investigation. Interviews with staff revealed that the resident had reported the incident to a registered nurse, who confirmed seeing the scratches and noted the resident's request not to be cared for by the accused staff members. The facility's administrator and director of nursing admitted that the accused staff were not suspended as per the facility's abuse prevention policy, which mandates suspension pending investigation. The director of nursing acknowledged not realizing that one of the accused staff members was still working during the investigation.
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Illustrative
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.
Illustrative
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Illustrative
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Nursing homes near Elk River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cura Of Monticello | 10.7 mi | ★★★★★ | 18 | 0 |
| Anoka Rehabilitation And Living Center | 10.8 mi | ★★★★★ | 6 | 0 |
| The Estates At Twin Rivers Llc | 10.9 mi | ★★★★★ | 2 | 1 |
| The Villas At Osseo Llc | 15.4 mi | ★★★★★ | 2 | 0 |
| Park River Healthcare And Rehabilitation Center Ll | 16.6 mi | ★★★★★ | 22 | 2 |
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