A list of the most recent deficiencies for The Guardian Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2022-11-10 | 2023-02-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-10 | 2023-02-21 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-10 | 2023-02-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-10 | 2023-02-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-10 | 2023-02-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-10 | 2023-02-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-10 | 2023-02-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-10 | 2023-02-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-10 | 2023-02-21 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-11-10 | 2023-02-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-10 | 2023-02-21 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-11-10 | 2023-02-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-10 | 2023-02-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-23 | 2023-02-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-10 | 2022-12-21 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-11-10 | 2022-12-21 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-11-10 | 2022-12-21 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-11-10 | 2022-12-21 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-11-10 | 2022-12-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-11-10 | 2022-12-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-11-10 | 2022-12-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-10 | 2022-12-21 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-11-10 | 2022-12-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-10 | 2022-12-21 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-11-10 | 2022-12-21 | N |
| Provide activities to meet all resident's needs. | Health | 2022-11-10 | 2022-12-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-10 | 2022-12-21 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-11-10 | 2022-12-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-10 | 2022-12-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-10 | 2022-12-21 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-11-10 | 2022-12-21 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-11-10 | 2022-12-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-10 | 2022-12-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-11-10 | 2022-12-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-10 | 2022-12-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-11-10 | 2022-12-21 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-11-10 | 2022-12-21 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-11-10 | 2022-12-21 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-11-10 | 2022-12-21 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-11-10 | 2022-12-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-10 | 2022-12-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-10 | 2022-12-21 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-11-10 | 2022-12-21 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-11-10 | 2022-12-21 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2022-11-10 | 2022-12-21 | N |
| Provide training in compliance and ethics. | Health | 2022-11-10 | 2022-12-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-08-24 | 2022-09-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-24 | 2022-09-28 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-03-01 | 2022-04-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-01 | 2022-04-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-01 | 2022-04-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-01 | 2022-04-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-17 | 2018-08-20 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2018-07-17 | 2018-08-20 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-07-17 | 2018-08-20 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2018-07-17 | 2018-08-17 | N |
