St. George Healthcare Center

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to keep the kitchen's large manual can opener, a kitchen oven, stove top spill pan, and four kitchen drawers which had food preparation and service equipment stored inside clean. These failures had the potential to create an environment for food-borne illnesses which could affect 80 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation, record review, staff interviews, and policy review, the facility failed to implement processes to ensure: 1. staff verified and signed that the controlled substance count was correct at each shift change in the narcotic count books, and 2. controlled medications were maintained in a safe and secure manner to prevent loss or diversion. These failures were identified in four of four medication carts ([NAME] Unit - Medication Carts #1 and #2; Stone Unit - Medication Carts #1 and #2) observed for medication storage and labeling. This deficient practice created the potential for drug diversion, medication theft, and improper handling of controlled substance returns, which could impact patient safety and the facility's compliance with medication management requirements.

Inspectors wroteBased on record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within the required timeframes specified for one of 23 sampled residents (Resident (R) 68) reviewed for MDS. This failure had the potential for inaccurate or incomplete care planning and/or provision to the residents, and/or a lack of appropriate payment for services to the facility.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure nursing staff were competent in gastric tube (GT) management, including verifying tube placement prior to flushing and performing GT replacement, for one of three residents (Resident (R) 6) reviewed for tube feeding management out of a total sample of 23. The facility failed to ensure staff competency was validated through return demonstration of GT-related skills, use of a competency checklist, and evaluation of staff performance following training prior to providing direct resident care. This failure placed R6 at risk for aspiration, respiratory distress, and injury if fluids were administered into a GT that was not correctly positioned or if the tube was improperly replaced at the bedside.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to provide the reason for transfer or discharge, to the resident and/or the resident representative upon discharge to the hospital, in writing for 2 of 2 residents (Resident (R)58 and R70) reviewed for transfer and discharge. This failure had the potential to affect residents' understanding for the reason of transfer.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to provide the complete Bed Hold to the resident and or the resident representative upon discharge to the hospital for 2 of 2 residents (Resident (R) 58) and R70) reviewed for transfer and discharge. This failure had the potential to affect the resident's knowledge on return to the facility.

Inspectors wroteBased on review of facility policy, interview, and record review, the facility failed to provide appropriate supervision for Resident (R)1, resulting in R1 successfully eloping from the facility, for 1 of 3 residents reviewed. On 09/18/24 at 3:35 PM, the Administrator was notified that the failure to ensure a resident receives appropriate supervision, to prevent an elopement, constituted Immediate Jeopardy at F689. On 09/18/24 at 3:35 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 09/15/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 09/18/24, the facility provided an acceptable IJ Removal Plan. On 09/18/24 the survey team, validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. [...]

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure Certified Nursing Assistant (CNA1) followed the resident positioning procedure during resident care for 1 of 2 residents (Resident (R) 16) reviewed for accidents out of a total sample of 21 residents. As a result of the deficient practice R16 fell and was harmed when she sustained bilateral leg fractures.

Inspectors wroteBased on review of facility policy, record review, observations, and interviews, the facility failed to ensure that one (Resident (R) 2) of 21 sampled residents were treated in a respectful and dignified manner during dining. Specifically, staff stood over the resident while feeding the resident the meal, rather than sitting at the resident's eye level, maintaining face-to-face contact.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to honor choices regarding meals for 1 (Resident (R) 32) of 1 resident reviewed for dialysis out of a total sample of 21 residents. Specifically, R32's choice of receiving his lunch meal upon return from dialysis.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident (R) 64) of 1 resident reviewed for urinary catheter received appropriate catheter care out of a total sample of 21 residents. The facility's deficient practice had potential to injure R64's urinary tract system.

Inspectors wroteBased on record reviews and interviews, the facility failed to conduct behavior tracking and monitor the side effects of antidepressant medication for 1 of 5 residents (Resident (R) 16) reviewed for unnecessary medications out of a total sample of 21 residents. These failures placed the residents at risk for not obtaining the intended therapeutic goal of the antidepressant medication and the potential for serious adverse effects from the antidepressant medications.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to decrease the dosage of a blood pressure medication when ordered by the physician for 1 resident (Resident (R) 55) of 5 residents reviewed for unnecessary medications out of a total sample of 21 residents. This deficiency had the potential for R55 to continue to experience unwanted side effects of a slow heart rate.