Geer Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Geer Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 4, 2026

  Based on observation, record and policy review, and interviews, the facility failed to maintain the resident environment as free of accident hazards and to provide adequate supervision consistent with the resident's assessed needs for 1 of 3 resident reviewed (Resident #58). Despite assessment and care-plan directives indicating supervision/touch assistance with eating and nectar-thick liquids, staff placed very hot coffee (dispensed from resident-accessible machines measured between approximately 178-182 F, with vendor settings later confirmed at 194 F and only reduced to 176 F) in front of Resident #58 without supervision, resulting in Resident #58 spilling coffee on his/her lap and sustaining a second-degree burn to the left thigh (blistering/open areas documented 3/6/26-3/20/26). […]

• Actual harm, isolatedF686May 4, 2026

  Based on observation, interviews, facility policy review and clinical record review, the facility failed to implement pressure-ulcer prevention consistent with professional standards of practice for 1 of 3 residents reviewed for pressure ulcers (Resident #58), who was repeatedly identified as high risk on Braden assessments (5/22/24, 2/29/25, 3/12//26, 4/6/26) but had no care-plan problem or prevention interventions addressing pressure-injury risk until after developing a facility-acquired Stage 2 coccyx ulcer on 4/6/26 (2.0 cm by 2.0 cm). […]

• Actual harm, isolatedF689Jan 21, 2022

  Based on review of the clinical record, facility documentation, facility policy, and interviews for one resident (Resident # 1) reviewed for accidents, the facility failed to ensure the resident received an assessment when the resident refused to ambulate and complained of pain to identify a potential serious injury timely. The findings include: Resident #1 was admitted on [DATE] with diagnoses that included syncope, glaucoma hypertension and dementia with behavioral disturbances. The Nursing Admission assessment dated [DATE] identified Resident #1 had no mobility issues, no balance issues and indicated the resident was able to ambulate with minimal assist. The assessment also noted no pain. The RCP dated 12/21/21 identified Resident #1 was at high risk for falls. […]

• No harm, potential for more than minimal, patternF657May 4, 2026

  Based on the facility policy, record review, and interviews for 1 of 4 sampled residents (Resident #34) reviewed for accidents, the facility failed to ensure the Resident Care Plan (RCP) was reviewed and revised after a fall to include added interventions to prevent further falls. Resident #34's diagnosis included dementia, hypertension, and atrial fibrillation.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #34 was cognitively intact and independent for eating. The MDS also identified Resident #34 required substantial/maximal assistance for bathing, dressing, and partial moderate assistance for transfers. […]

• No harm, potential for more than minimal, patternF880May 4, 2026

  Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 residents (Resident #58) reviewed for pressure ulcer/injuries, the facility failed to ensure appropriate personal protective equipment (PPE) was donned (placed on) prior to incontinent care for a resident on enhanced barrier precautions (EBP) and failed to ensure staff handled soiled items and linens appropriately and for Resident #82, the facility failed to ensure personal care items were properly labeled, covered, and stored according to facility policy and in a manner to maintain a clean environment. The findings included: 1. […]