St. Gertrudes Health & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess, monitor, and/or treat skin conditions for 2 of 3 residents (R2, and R3) reviewed for skin integrity.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were available for administration per physician order for 1 of 3 resident (R1) reviewed for quality of care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in a walk-in freezer. The facility failed to ensure scoops were not stored in 2 of 3 bulk containers to prevent cross contamination. The facility also failed to ensure hair and beard nets were used in the food preparation area and kitchen utensils sanitizing area. In addition, the facility failed to consistently monitor the dishwasher machine temperature. This had the potential to affect all 98 residents, staff, and visitors who consumed food from the facility kitchen.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a resident was appropriately assessed and had an appropriate order in place to self-administer nebulizer medication for 1 of 1 resident (R80) reviewed for self-administration of medications.

Inspectors wroteBased on observation and interview, the facility failed to accommodate resident needs by ensuring the call light was accessible for 1 of 1 resident (R26) reviewed for call lights.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident rooms were maintained at a comfortable temperature between 71 and 81 degrees Fahrenheit for 1 of 1 residents (R57) reviewed who indicated their rooms were cold. Findings Include:R57's admission Minimum Data Set (MDS) assessment, dated 12/22/25, indicated a diagnosis of cerebral infarction (stroke) with intact cognition. During an interview on 1/12/26 at 5:19 p.m., R57 stated his room was cold. R57 was observed wearing a winter coat while sitting in a recliner chair in his room between the bed and the window which he reported was where he spent the majority of his time. R57 stated he had reported his concerns to staff and had been told this room is always like this. R57 stated, I am froze. The thermostat on the wall indicated 72.9 degrees Fahrenheit (F). [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to provide and document an appropriate diagnosis for a prescribed psychotropic medication for 1 of 5 (R100) residents and failed to provide appropriate side effect monitoring (i.e., orthostatic blood pressure) with antipsychotic medication consumption for 1 of 3 (R49) residents reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review the facility failed to ensure a resident's preferences were care planned to ensure preferences were honored for 1 of 1 resident (R127) reviewed who preferred to have female only caregivers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 4 residents (R45) reviewed for activities of daily living (ADLs) and were dependent on staff for their ADLs, routinely had their fingernails cleaned and trimmed.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure communication and collaboration was maintained with a dialysis provider for 1 of 1 resident (R7) reviewed for dialysis.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from abuse for 1 of 3 (R1) residents when registered nurse (RN)-A witnessed nursing assistant (NA)-A respond to R1 by punching him in the leg when providing cares.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate allegations of witnessed physical abuse for 1 of 3 residents (R1) reviewed for abuse investigation when the facility did not interview any residents to determine if they were abused. Registered nurse (RN)-A witnessed nursing assistant (NA)-A respond to R1 by punching him in the leg when providing cares.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement the care plan for 1 of 3 residents (R1) reviewed for care plan interventions when R1 was to have cares in pairs (two staff with resident) and was to be transferred using a Sara Steady (a mechanical sit to stand machine) and was observed with staff transferring without the device.

Inspectors wroteBased on interview and document review, the facility failed to ensure the resident representative was notified in a timely manner of a deterioration in wound status for 1 of 3 residents (R1) reviewed for non-pressure skin impairments.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess the bowel and bladder status to determine what, if any, proactive interventions were needed to help promote healing of developed moisture-associated skin damage (MASD; a type of skin damage that occurs when skin is exposed to prolonged moisture, leading to inflammation and erosion) for 1 of 3 residents (R1) reviewed for non-pressure skin impairments.

Inspectors wroteBased on observation, interview, and record review the facility failed to report an injury of unknown origin to the State Agency (SA) immediately, but not later than two hours after the allegation is made for 1 of 3 residents assessed. Staff assisted R1 with a transfer using a sit-to-stand lift (a device that assists people with limited mobility to move from a seated position to a standing position) for toileting. R1's legs became weak, she needed to be sat down, and was lowered to the toilet. Approximately six hours later R1 woke-up in extreme pain, was sent to the emergency department (ED) and an x-ray revealed a fractured clavicle (one of the bones at the base of the neck, collar bone).

Inspectors wroteBased on observation, interview and document review the facility failed to assess and determine what, if any, options were available to help facilitate bathing method preference (i.e., showers) for 1 of 1 resident (R33) who voiced feeling unsafe being transported for distance while seated in the shower chair.

Inspectors wroteBased on interview and document review, the facility failed to ensure routine grooming was offered or provided to promote good hygiene for 2 of 2 residents (R1, R25) reviewed for activities of daily living (ADLs) and who were dependent on staff for their cares.

Inspectors wroteBased on interview and document review, the facility failed to ensure complaints of potential constipation were acted upon and assessed to determine what, if any, interventions were needed to promote appropriate bowel management and reduce the risk of complication (i.e., fecal impaction) for 1 of 2 residents (R59) reviewed for bowel management.

Inspectors wroteBased on observation, interview and document review the facility failed to assess for removal of an indwelling urinary catheter as soon as possible to restore urinary continence for 1 of 1 residents (R27), reviewed for catheter care.

Inspectors wroteBased on the interview and document review, the facility failed to ensure the consulting pharmacist's recommendations were fully addressed or acted upon for 1 of 5 residents (R66) who were reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were available in a timely manner to be provided in accordance with physician orders for 1 of 6 residents (R302) reviewed for medication administration. This resulted in multiple omitted doses and constituted two (2) errors from 27 opportunities for a facility' error rate of 7.14% (percent).

Inspectors wroteBased on observation and interview, the facility failed to ensure residents had access to all the survey results for the past 3 years along with the plan of correction (POC), without having to ask, for the most recent survey of the facility. This had the potential to affect all 88 residents, families, and visitors who may wish to view these.

Inspectors wroteBased on interview and document review, the facility failed to perform timely comprehensive skin assessments, follow physician orders to provide treatment and services to heal and prevent pressure ulcer infection for 1 of 3 residents (R1) reviewed for pressure ulcers. The facility's failure resulted in harm to R1 who developed a stage 4 pressure ulcer with osteomyelitis and associated cellulitis requiring hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were available for administration per physician order for 2 of 3 residents (R2 and R8) reviewed for resident safety.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess and develop interventions within the resident' environment to ensure safety and reduce the risk of avoidable injuries for 1 of 1 resident (R11) reviewed who demonstrated repeated behavior of placing their legs off the bedside and whose bed was placed next to an active heating element. These findings constituted an immediate jeopardy (IJ) situation, and substandard quality of care, for R11 when their feet were found directly on the heating element after an extended period of time resulting in multiple, full thickness burns and subsequent hospitalization. The IJ began on 12/13/23, when it was identified R11 had sustained multiple burns to their feet because their bed had been placed adjacent to an active, wall-mounted heating element. [...]

Inspectors wroteBased on observation and interview and policy review, the facility failed to ensure medications were securely stored safely in 2 of 6 mediation carts observed.

Inspectors wroteBased on observation and interview, the facility failed to ensure contracted staff followed standard infection control practices when preforming blood draws for 1 of 1 residents (R297) with the potential to affect 8 residents (R81, R294, R295, R296, R297, R341, R342, R343) residing on the sub-acute 300 unit with access to the dining/common area unit tables, observed for blood draws.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure implemented care interventions (i.e., transmission-based precautions; TBP) were adequately explained or communicated to promote knowledge and understanding for 1 of 2 residents (R149) reviewed for participation in care planning.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure appropriate treatment and services were provided to maintain and/or improve hearing and communication for 2 of 2 (R26, R63) residents reviewed for hearing.

Inspectors wroteBased on observation, interview, and document review, the facility failed to attempt alternatives before installing half-side rails on a bed, failed to assess the resident for risk of entrapment, and failed to review the risks and benefits of bed rails and obtain informed consent with the resident or their representative for 1 of 1 residents (R71) reviewed who had rails on their beds.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the facility' state survey results were kept in a location which was readily-accessible to all residents (i.e., in a wheelchair). This had potential to affect all 86 residents and/or visitors who could wish to review the information.

Inspectors wroteBased on interview and document review, the facility failed to complete an annual performance review for 1 of 3 nursing assistants whose employee files were reviewed. This had the potential to affect all 86 residents who resided at the facility.