St George Healthcare Center

In the surveyor’s words

From the most serious findings on record at St George Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 19, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF600Jun 27, 2023

  Based on interview and record review, the facility failed to provide services to Resident (R)1 necessary to R1 to avoid physical harm, pain, mental anguish, or emotional distress for 1 of 9 residents reviewed. R1 exited the facility on 06/22/2023 at approximately 7:55 AM and was found at 8 AM. Certified Occupational Therapy Assistant (COTA)1 found the resident in the receptionist's car. This was confirmed by the receptionist, administrator, housekeeping staff #1 and #2, Certified Nursing Aide (CNA)1, and the Assistant Director of Nursing. The resident was known to be an elopement risk, but no interventions were put in place to protect the resident from elopement. […]

• Immediate jeopardy, isolatedF689Jun 27, 2023

  Based on interview and record review, the facility failed to provide supervision necessary to prevent elopement for 1 of 9 residents reviewed. R1 eloped from the facility on 06/22/2023 at approximately 7:55 AM and was found at 8 AM. Certified Occupational Therapy Assistant (COTA)1 found the resident in the receptionist's car. This was confirmed by the receptionist, administrator, housekeeping staff #1 and #2, Certified Nursing Aide (CNA)1, and the Assistant Director of Nursing. The resident was known to be an elopement risk, but no interventions were put in place to protect the resident from elopement. […]

• Actual harm, isolatedF689Feb 8, 2023

  Based 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. Findings include: Review of the facility's undated policy titled, Hartman's Nursing Assistant Basics Fifth Edition revealed when positioning a resident .Gently slide your hands under the resident's head and shoulders and move them toward you. Gently slide your hands under her midsection and move it toward you. Gently slide your hands under the hips and legs and move them toward you . […]

• Actual harm, isolatedF806Sep 8, 2022

  Based on review of facility policy, record review, and interviews, the facility failed to ensure Resident (R)6 was served meals in accordance with allergies, intolerances, and preferences for 1 of 2 residents reviewed for Nutrition. Specifically, the facility served R6 shrimp, which had the potential of resulting in a life threatening incident. Findings include: Review of the facility's policy titled, Nutrition dated 08/01/20, revealed The Nutrition Service Director (NSD) or designee is responsible for training culinary staff on how to handle foods to avoid any inappropriate foods being served to patients or residents with food allergies. This may include special designated food preparation space in the case of life threatening food allergies. […]