St. George Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jun 7, 2024

  Based on observation, interview, and facility policy review, the facility failed to store, prepare, and serve food in a sanitary manner for 1 of 2 nourishment refrigerators and 1 of 1 kitchen. Specifically, the staff failed to date foods brought in from visitors to be stored in the nourishment refrigerators and discard opened food items that were undated and had been in the nourishment refrigerators for an indeterminate amount of time. Additionally, the staff failed to change gloves and wash their hands after touching high-contact surfaces and before touching food items. This had the potential to affect 96 of 96 residents who received food from the dietary department. Findings included: 1. A facility policy titled, [Facility Name] Policy / Procedure, revised 11/2016. […]

• No harm, potential for more than minimal, patternF584Jan 12, 2023

  Based on observation and interview, it was determined, for 4 of 24 sampled residents, that the facility did not provide each resident with a safe, clean homelike environment. Specifically, a resident had plastic in the corner of her room where the roof had leaked, there were gashes in the drywall behind a resident's bed, wheelchair was soiled, and rooms had trash and debris on the floor. Resident identifiers: 8, 28, 73 and 128. Findings included: 1. On 1/9/23 at 4:16 PM, resident 73 was interviewed. Resident 73 stated that approximately 1 week ago, it had rained and that the wall and ceiling near the window had leaked water. Resident 73 stated that the maintenance stopped by and told her the room was being looked at. […]

• No harm, potential for more than minimal, patternF677Jun 1, 2022

  Based on interview and record review, it was determined, for 3 of 11 sampled residents, that the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, residents were not provided showers according to their schedules. Resident identifiers: 2, 3, and 5. Findings include: 1. Resident 3 was initially admitted to the facility on [DATE] and again on 3/4/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with resident 3 was conducted on 6/1/22 at 9:15 AM. Resident 3 stated that she typically preferred bed baths. Resident 3 stated that she was supposed to get a bed bath twice a week. […]

• No harm, potential for more than minimal, patternF880Jun 1, 2022

  Based on observations, interviews, and record review, it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of staff without proper eye protection while the facility was located in a high transmission categorized county, and observations were made of staff not wearing required Personal Protective Equipment (PPE) in resident care areas and Coronavirus Disease 2019 (COVID-19) isolation areas. […]

• No harm, potential for more than minimal, patternF808May 20, 2021

  Based on observations, interviews and record reviews it was determined, for 4 of the 34 residents, that the facility did not provide therapeutic diets prescribed by the attending physician or licensed dietitian. Specifically, 4 residents had orders in their electronic medical record for consistent carbohydrate diet (CCHO) and were provided a regular diet per their meal tray tickets. Resident identifiers: 22, 32, 51, 257. Findings include: 1. On 5/17/21 at 5:33 PM, during dinner meal tray pass resident 22's tray ticket was observed to read, Diet Order: *REGULAR. On review of resident's electronic medical record his diet order read CCHO diet. 2. Tray tickets, diet orders and nutrition evaluation notes were reviewed for consistency in diet orders. a. […]