Guardian Angels Health & Rehab Center
Inspection Findings
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
on 8/12/25. Resident R3's progress note dated 8/12/25 at 11:44 a.m., identified Resident R3 had no hydromorphone at the facility, MD-B was called and left a message to advise on Resident R3's pain medication. On 8/12/25 at 1:48 p.m., a progress note identified a nurse from MD-B's office called the facility and stated a new order was sent to pharmacy on 8/11/25. Facility called pharmacy but pharmacy phone was not working. On 8/13/25 at 9:02 a.m., a progress note identified the pharmacy received new orders for Resident R3's hydromorphone and would be delivering the medication as soon as possible. During an interview on 8/19/25 at 11:31 a.m., Resident R1 stated she had not received her pain medication in the past due to not having any in the facility. During an interview on 8/20/25 at 7:48 a.m., licensed practical nurse (LPN)-A stated Resident R1 had ran out of pain medications twice. At times, the providers did not reply to our requests for new pain medication prescriptions and residents would run out of their pain medications. During an interview on 8/20/25 at 9:53 a.m., Resident R3 stated he did run out of his pain medications and the facility told him they would keep a better eye on his medication to ensure he did not run out again. During an interview on 8/20/25 at 12:10 p.m., registered nurse (RN)-A stated she did not believe the facility received medications for residents in a timely manner. RN-A called MD-A about Resident R1 running out of her pain medication and MD-A stated not to call him just fax. RN-A explained to MD-A that not getting pain medications in a timely manner was an issue. During an interview on 8/20/25 at 12:34 p.m.,
the director of nursing stated the facility had a system issue when it came to pharmacy services and physician's responses. As a result, the medications not received timely at the facility for residents. During an
interview on 8/20/25 at 1:22 p.m., MD-A stated the pharmacy would not accept verbal orders for pain medications, so residents were running out of their pain medications at the facility. During an interview on 8/20/25 at 1:32 p.m., the consultant pharmacist stated the pharmacy could only take verbal orders for narcotics if it was an emergency. Pharmacy did not receive timely faxed orders and as a result, residents were running out of pain medications. During an interview on 8/20/25 at 2:35 p.m., the administrator stated
it was expected that residents had their order medications and were given the medications per orders. The facility planned to work on a solution with the pharmacy and MD-A to ensure residents did not run out of their medications in the future. The facility policy Ordering and Receiving Medications undated, indicated reorder medications three to five days in advance of need to assure an adequate supply was on hand.
When reordering medications that require special processing (such as Schedule II controlled substances), order at least seven days in advance of need.
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If continuation sheet
Guardian Angels Health & Rehab Center in HIBBING, MN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in HIBBING, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Guardian Angels Health & Rehab Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.