C-
55/100GUARDIAN ANGELS CARE CENTER Inspection Report, Violations & Safety Grade (ELK RIVER, Minnesota)
400 EVANS AVENUE, ELK RIVER, Minnesota 55330
Phone: 7636355475
CMS Overall:2/5
Overview & Bed Count
Certified Beds
120
Avg Residents/Day
106.4
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
County
Sherburne
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health2/5
Staffing4/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Minnesota Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.48 | 1.08 | +0.40 |
| Total Nurse Hours per Resident per Day | 4.72 | 4.27 | +0.45 |
| CMS Staffing Rating | 4/5 | 4.2/5 | - |
| Nursing Staff Turnover | 53.9% | 42.1% | - |
Health Citation History
18 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-03-19 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2025-09-09 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-04-24 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2025-01-24 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | L – Immediate Jeopardy |
| 2025-01-24 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2025-01-24 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E – Moderate Harm Potential |
| 2025-01-24 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2025-01-24 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-01-24 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2025-01-24 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-09-12 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | D – Moderate Harm Potential |
| 2024-07-17 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | J – Immediate Jeopardy |
| 2024-05-16 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2024-04-11 | Resident Rights Deficiencies | 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. | J – Immediate Jeopardy |
| 2024-04-11 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | D – Moderate Harm Potential |
| 2024-04-11 | Quality of Life and Care Deficiencies | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D – Moderate Harm Potential |
| 2024-04-11 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2024-03-14 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
Fire Safety Citation History
12 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-10 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2025-12-10 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper storage of liquid oxygen. | D – Moderate Harm Potential |
| 2025-12-10 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | C – Minimal Harm Potential |
| 2025-01-24 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2025-01-24 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2025-01-24 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2025-01-24 | Egress Deficiencies | Have horizontal exits used in accordance with safety requirements. | D – Moderate Harm Potential |
| 2025-01-24 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2025-01-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2025-01-24 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | C – Minimal Harm Potential |
| 2024-04-11 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2024-04-11 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
Total Penalties & Fines
$98,353
Total Fine Amount (CMS)
4
Number of Fines
5
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-01-24 | Fine | $59,010 | - |
| 2025-01-24 | Payment Denial | - | 26 days starting 2025-02-26 |
| 2024-07-17 | Fine | $13,627 | - |
| 2024-05-16 | Fine | $16,801 | - |
| 2024-03-14 | Fine | $8,915 | - |
Need Help Finding Safe Care?
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the ELK RIVER area at no cost.
Find Safe, Vetted Facilities Near ELK RIVER
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.