St Gerard's Community of Care

In the surveyor’s words

From the most serious findings on record at St Gerard's Community of Care, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jun 13, 2024

  Based on observation, record review, review of facility policy, and family and staff interviews, the facility failed to ensure 3 of 3 supplemental residents (Resident #13, #19, and #23) with impaired cognition and unable to consent were free from resident to resident abuse. Failure to assess, care plan, and operationalize a plan/process may result in unwanted physical and/or sexual contact and may cause residents to experience fear, anxiety, and psychosocial harm. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 06/09/24. […]

• Immediate jeopardy, patternF610Jun 13, 2024

  Based on observation, record review, review of facility policy, and family and staff interview, the facility failed investigate incidents of resident to resident abuse for 3 or 3 supplemental resident (Resident #13, #19, and #23) with impaired cognition and unable to consent. Failure to investigate incidents of abuse may result in unwanted physical and/or sexual contact and may cause residents to experience fear, anxiety, and psychosocial harm. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 06/09/24. The facility failed to investigate resident to resident abuse. […]

• No harm, potential for more than minimal, widespreadF607Jun 13, 2024

  Based on review of facility policy, record review, and staff interview, the facility failed to protect all residents in the facility (31 of 31 residents) by failing to screen unlicensed employees prior to employment. Failure to screen unlicensed employees placed all residents at risk for abuse, neglect, exploitation, and misappropriation of resident property. Findings included: Review of the facility policy titled Abuse, Neglect, and Exploitation occurred on 06/13/24. This policy, revised June 2023, stated, It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. A. Screening 1. […]

• No harm, potential for more than minimal, patternF609Jun 13, 2024

  Based on observation, record review, review of facility policy, and family and staff interview, the facility failed to report incidents of resident to resident abuse to the Administrator and State Survey Agency (SSA) for 3 of 3 supplemental residents (Resident #13, #19, and #23) with cognitive impairments and unable to consent. Failure to report incidents of abuse may result in unwanted physical and/or sexual contact and may cause residents to experience fear, anxiety, and psychosocial harm. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation Policy occurred on 06/13/24. This policy, dated June 2023 stated, . It is the policy of St. Gerard's Community of Care to provide protections for the health, welfare and rights of each resident . A. […]

• No harm, potential for more than minimal, patternF689May 11, 2022

  Based on observation, review of facility policy, and staff interview, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 4 of 4 residents (Resident #9, #13, #14, and #377) observed being transported in a wheelchair with his/her feet dragging on the floor. Failure to utilize foot pedals on a wheelchair during transport has the potential to result in falls and/or injury. Findings include: Review of the facility policy Transporting Residents in Wheelchairs occurred on 05/11/22. This policy, dated February 1995, stated, . To transfer the resident to the wheelchair, the escort should: . 4. Adjust footrests and leg supports. During the trip, the escort should: . 5. […]