St Gertrudes Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at St Gertrudes Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 12, 2024

  Based on observation, interview and document review, the facility failed to comprehensively assess, develop and implement safe smoking interventions to reduce the risk of avoidable injuries with tobacco products for 4 of 4 residents (R2, R4, R7 and R3), who smoked. These failures resulted in an immediate jeopardy (IJ) for R2 who was smoking unsupervised outside the doors of facility's attached assisted living (AL), caught fire, sustained burns to 90% of her body, and died as a result of her injuries. The IJ began on [DATE], when a recommendation from physical therapy identified R2 was not safe smoking independently unsupervised. The facility had not developed and implemented safe smoking interventions for R2 including but not limited to supervision. […]

• Immediate jeopardy, isolatedF689Dec 14, 2023

  Based on observation, interview and document review, the facility failed to comprehensively assess and develop interventions within the resident' environment to ensure safety and reduce the risk of avoidable injuries for 1 of 1 resident (R11) reviewed who demonstrated repeated behavior of placing their legs off the bedside and whose bed was placed next to an active heating element. These findings constituted an immediate jeopardy (IJ) situation, and substandard quality of care, for R11 when their feet were found directly on the heating element after an extended period of time resulting in multiple, full thickness burns and subsequent hospitalization . […]

• Actual harm, isolatedF686Feb 12, 2024

  Based on interview and document review, the facility failed to perform timely comprehensive skin assessments, follow physician orders to provide treatment and services to heal and prevent pressure ulcer infection for 1 of 3 residents (R1) reviewed for pressure ulcers. The facility's failure resulted in harm to R1 who developed a stage 4 pressure ulcer with osteomyelitis and associated cellulitis requiring hospitalization . Findings include: Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink, or red, moist, and may also present as an intact or open/ruptured blister. […]

• No harm, potential for more than minimal, widespreadF812Jan 15, 2026

  Based on observation, interview, and document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in a walk-in freezer. The facility failed to ensure scoops were not stored in 2 of 3 bulk containers to prevent cross contamination. The facility also failed to ensure hair and beard nets were used in the food preparation area and kitchen utensils sanitizing area. In addition, the facility failed to consistently monitor the dishwasher machine temperature. […]

• No harm, potential for more than minimal, widespreadF886Sep 15, 2022

  Based on interview and document review, the facility failed to test staff for COVID-19 according to Centers for Medicare and Medicaid (CMS) guidance for routine testing requirements for 2 of 3 staff (NA-H, LPN-E) reviewed for COVID-19 testing. This deficient practice had the potential to affect all 82 residents in the facility, all staff, and any visitors to the facility. Findings include: The CMS QSO-20-38-Nursing Home memo revised 3/10/22, directed all facilities located within a high or substantial county community transmission level to conduct twice weekly routine COVID-19 testing for all staff who were not up to date with the required COVID-19 vaccinations . Up-to-Date means a person has received all recommended COVID-19 vaccines, including any booster dose(s) when eligible. […]