Advanced Health Care of St. George

In the surveyor’s words

From the most serious findings on record at Advanced Health Care of St. George, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761May 15, 2025

  Based on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the expiration date when applicable. Specifically, for 3 out of 22 sampled residents, five opened insulin injector pens were not labeled with open dates or a discard date, and they were in the medication cart available for resident use. Resident identifiers: 104, 107, and 109. Findings included: On 5/14/25 at 9:29 AM, an observation was conducted of the Hall 3 medication cart with Licensed Practical Nurse (LPN) 1. There were five insulin injector pens in the medication cart that were not labeled with an open date or a discard date. […]

• No harm, potential for more than minimal, isolatedF760May 15, 2025

  Based on interview and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 22 sampled residents, a resident taking an anticoagulant medication received two doses in error on one day. Resident identifier: 109. Findings included: Resident 109 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, persistent atrial fibrillation and long term use of anticoagulants. On 5/12/25 at 3:50 PM, an interview was conducted with resident 109. Resident 109 stated the facility International Normalized Ratio (INR) machines did not work. Resident 109 stated the nurse went through three machines the other day before she could get a reading. […]

• No harm, potential for more than minimal, isolatedF773May 15, 2025

  Based on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner, or clinical nurse specialist. Specifically, for 1 out of 22 sampled residents, a resident had a basic metabolic panel (BMP) and complete blood count (CBC) collected without a physician's order. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, sepsis due to methicillin susceptible staphylococcus aureus, pneumonia, chronic respiratory failure with hypoxia, systolic heart failure, chronic kidney disease, and anemia. Resident 15's medical record was reviewed. An interim lab report was located within resident 15's medical record. […]

• No harm, potential for more than minimal, isolatedF880May 15, 2025

  Based on observation and interview, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, for 1 out of 22 sampled residents, a nurse did not perform hand hygiene, assisted a pill with their bare finger from the medication bottle to the medication cup, and administered the medications to a resident. Resident identifier: 97. Findings included: On 5/14/25 at 7:56 AM, Licensed Practical Nurse (LPN) 2 was observed to prepare and administer medications to resident 97. LPN 2 was observed to assist a pill with their bare finger from the medication bottle to the medication cup with the other prepared medications. LPN 2 was observed to administer the medications to resident 97. […]

• No harm, potential for more than minimal, isolatedF580Jun 29, 2023

  Based on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not consult with the resident's physician and notify when there was a significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment. Specifically, the resident had elevated blood sugar levels while waiting for the arrival of their insulin pen and the physician was not notified. Resident identifier 77. Findings included: Resident 77 was admitted to the facility on [DATE] with diagnoses which consisted of type 2 diabetes mellitus (DM), morbid obesity, postprocedural seroma of skin, urinary tract infection, hypothyroidism, hyperlipidemia, depression, hypertension, repeated falls, and long term use of insulin. […]