Saint Vincent Healthcare

Inspectors wroteBased on observation, interview, and review, the facility failed to provide care in a manner that maintained a resident's dignity and respect for three of three sampled residents (Residents 3, 57, and 65) under dignity care area by failing to ensure facility staff were at eye level while assisting the residents during meals. This deficient practice had the potential to affect Resident 3, 57, and 65's self-esteem and self-worth.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and intervention to prevent accidents or injury for three (3) of five (5) sample residents (Resident 4 and 20) under the Accidents care area in accordance with the facility's policy and procedure when: 1. The facility did not ensure Residents 4 was not in the room while the housekeeping was mopping the floor on 11/18/2025.2. The facility did not ensure Resident 20 was not in the room while housekeeping was mopping the floor on 11/18/2025 and was reoriented and redirected back to her room while wandering (to move around different places usually without having a particular purpose or direction) on 11/20/2025 and 11/21/2025. These deficient practices placed Resident 4 and 20 at risk for accident and/ or injury.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide privacy and confidentiality (safeguarding the content of information from unauthorized disclosure without the consent of the Resident and/or the individual's surrogate or representative) for one of 18 sampled residents (Resident 48) when Resident 48's name, room number, and post-op wound care instructions were left posted outside the residents room. This deficient practice violated Resident 48's right to privacy and confidentiality.

Inspectors wroteBased on interviews, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that every resident entering a Medicaid Certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II Evaluation to ensure that the NF residence is appropriate and to identify what specialized services the resident may need) for one (1) of two (2) sampled residents (Resident 4) under PASRR care area, in accordance with the facility's policy. This deficient practice had the potential to result in inappropriate placement of Resident 4 and had the potential for not receiving the necessary and appropriate level of treatment and evaluation in the facility.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 4) received monitoring and care for the left eye redness as indicated on the care plan and in accordance with the facility's policy. This deficient practice had the potential to negatively affect Resident 4's physical comfort and well-being caused by delay in receiving necessary treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to one of one sampled resident (Resident 5) who requires dialysis (the medical necessity for ongoing removal of waste and excess fluid from the blood to sustain life due to permanent kidney failure) by failing to accurately monitor the resident's fluid intake and to follow the physician's order for fluid restriction of 1000 milliliters (ml- unit of measurement for volume) a day. This deficient practice had the potential to place Resident 5 at risk for fluid overload recurrence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of six sampled residents (Resident 47) in accordance with the facility's policy and procedure (P&P) by failing to:1. Administer ferrous sulfate (a supplement used to treat or prevent iron deficiency, a condition that can lead to tiredness) every other day as ordered. 2. Administer Vitamin C (a supplement that the body needs to form collagen for skin, blood vessels, and bones, to heal wounds, and to protect cells from damage) daily as ordered. These deficient practices had the potential for Resident 47 to experience tiredness, shortness of breath, bruise or bleed easily, and poor wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a debris-free dumpster area when trash was not properly contained, uncovered, and overflowing for two of five trash bins. This failure had the potential to result in pests (an organism that causes harm to humans such as flies, cockroaches, and rodents) entering the facility and spreading diseases to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was documented evidence of the hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) visits and coordination in the resident's medical record for one (1) of 1 sampled resident (Resident 10) from the Hospice care area in accordance with the facility's policy and procedure ) titled, Hospice Program. This deficient practice had the potential to result in a delay or lack of coordination in the delivery of hospice care and services to Resident 10.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (2) of 27 rooms (rooms [ROOM NUMBERS]) accommodated no more than four (4) residents in each room. rooms [ROOM NUMBERS] have five (5) beds. This deficient practice has the potential for the residents' care and services not to be adequately accommodated, have an adverse effect on the residents' safety, and place residents at risk for lack of privacy. During the initial tour of the facility on 11/18/2025 from 9 AM to 9:15 AM, there were two rooms (13 and 14) observed with five beds in a room. The residents in rooms [ROOM NUMBERS] did not complain regarding the space in their room. There was enough space for the staff to provide care and enough storage for residents' belongings. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the minimum of 80 square feet (sq.ft. - unit of measurement) per resident bed in 25 of 27 resident rooms in the facility. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents. During an observation of the residents' rooms one (1) to nine (9) and 11 to 26 on 10/18/2025 from 9 AM to 3:48 PM, 25 of 27 resident rooms did not meet the minimum 80 sq ft per resident in each room. The residents did not complain regarding the space in their room. There was enough space for the staff to provide care and enough storage for residents' belongings. All the Residents including the ones who were ambulatory and wheelchair bound were able to move in and out of the room without difficulty. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: 1. Properly store frozen food items in the kitchen freezer. 2. Properly store and label dry pasta in sealed containers. 3. Ensure there were no expired foods in the kitchen. These deficient practices had the potential to result in food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) in a population of 67 residents consuming food by mouth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (2) of 2 garbage container (dumpster) lids remained closed and were not overflowing with trash in accordance with the facility's policy. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g. rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP - an infection control practice that involves wearing gloves and gowns during high-contact patient care activities to reduce the spread of multidrug-resistant organisms [MDROs- microorganisms that are resistant to multiple classes of antibiotics and antifungals]) for 11 of 11 sampled residents on EBP (Residents 27, 3, 7, 21, 23, 42, 69, 225, 28, 1, and 24) as indicated in the facility policy, by failing to ensure: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the foley catheter (a flexible tube that drains urine from the bladder into a collection bag outside of the body) was covered with a dignity bag (a bag that covers and holds a foley catheter drainage bag to keep it out of sight) for one of 18 residents (Resident 225). This deficient practice had the potential to result in Resident 225 having decreased feelings of self-worth and/or self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of one (1) of three (3) sampled residents (Resident 63) by failing to provide a pad call light (a device for residents who have difficulty using a call light cord). This failure had the potential for Resident 63's needs to not be met, resulting in a lowered quality of care and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) interventions for one (1) of 18 residents (Resident 3), were applicable and resident-centered. This failure had the potential for Resident 3 to receive inappropriate and/or inadequate services which could harm the resident.

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to meet professional standards of quality for assessing one (1) of five sampled residents (Resident 72) by failing to ensure Resident 72 was assessed and evaluated by Medical Doctor (MD) before adding a new diagnosis of schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others ) according to accepted standards of clinical practice. This deficient practice had the potential to result in provision of unnecessary care for Resident 72.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 18 sampled residents (Resident 2) with limitations in mobility was provided assistance while eating as indicated in the care plan and facility policy. This deficient practice had the potential for decline and not to maximize Resident 2's functional ability to perform activities of daily living (ADL), which can affect the resident's physical and mental wellbeing. This failure also had the potential not to meet Resident 2's nutritional needs which could lead to malnutrition (a condition that occurs when a person's body doesn't get the right amount of nutrients it needs to function properly) and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to provide the necessary treatment and services for one of one sampled residents (Resident 24) by failing to ensure Resident 24 received treatment for right heel (ankle) stage 3 (full-thickness loss of skin, dead and black tissue may be visible) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) from 10/1/2024 to 10/7/2024 as indicated in Resident 24's wound treatment plan. This deficiency had the potential for Resident 24's right heel stage 3 pressure injury to worsen and had the potential to develop an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the head of bed (HOB) was elevated at 30 degrees angle for one (1) of 1 sampled Resident (Resident 28) while receiving gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (GT) feeding in accordance with the facility's policy. This failure has the potential for Resident 28 to aspirate (feeding could enter the windpipe and lungs) which could lead to lung problem such as pneumonia (an infection/inflammation of the lungs).

Inspectors wroteBased on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas) for one (1) of three (3) sampled residents (Resident 35) who was diagnosed with post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) in accordance with the facility's policy. This deficient practice had the potential for Resident 35 to experience re-traumatization, (unintentionally causing harm through practices, policies, and/or activities that are insensitive to the needs of the residents) that could lead to severe psychosocial harm and negatively affecting Resident 23's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registry (a placement service that provides staff on a temporary or day-to day basis in a facility) Certified Nursing Assistant 1 (RCNA 1) had the competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) in skill sets necessary before providing care to residents in the facility. RCNA 1 worked in the facility on 10/17/2024. This deficient practice had the potential for residents to not receive appropriate nursing services and had the potential to place residents at risk for injury or harm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 68) was free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to have a clinical justification for the use of Risperdal (medication used to treat schizophrenia [a serious mental illness that affects a person's ability to think, feel, and behave], bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs], and autism spectrum disorder [ASD - a complex developmental condition that affects how people interact, communicate, and behave]) without a clinical justification for use. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the resident personal food choices for one of eighteen (18) sampled residents (Resident 68) in accordance with the care plan and facility policy by failing to: 1. Follow Resident 68's food preference for Mexican food on 11/20/2023 and 5/10/2024. 2. Provide Resident 68 requested tacos on 1/25/2024, 1/30/2024 and 2/8/2024. 3. Provide Resident 68 requested beef soup on 1/26/2024. This deficient practice failed to accommodate Resident 68's food preference which had the potential to result in weight loss and affect the resident's psychological, physical, and emotional well-being.

Inspectors wroteBased on interview and record review, the facility failed to offer the pneumococcal vaccine (a medical injection that protects against the bacteria Streptococcus pneumoniae) for one of five sampled residents (Resident 2) upon readmission on [DATE] as indicated in the facility's policy. This failure placed Resident 2 at a higher risk of acquiring preventable infections such as pneumonia (PNA- an infection in your lungs), bacteremia (infection of the blood), or meningitis (infection of the tissue covering the brain and spinal cord) and increased the risk of transmission to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the minimum of 80 square feet (sq.ft.) per resident bed in 25 of 27 residents' rooms in the facility. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.

Inspectors wrote2. A review of Resident 36's admission Record, indicated Resident 36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of COPD, morbid obesity (abnormal or excessive fat accumulation), and diabetes mellitus type 2 (high blood sugar). A review of Resident 36's Quarterly Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/9/2023, indicated the resident had an active diagnosis of COPD with acute exacerbation. A review of Resident 36's COPD care plan, dated 7/4/2023, indicated the care plan was not revised according to the re-evaluation date on the care plan. A review of Resident 36's care plan on 11/2/2023 at 10:03 AM, indicated Resident 36's quarterly COPD care plan's re-evaluation date listed as 10/2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four (3) of five (5) Residents (Resident 3, 5, and 45) were hydrated as indicated on the facility policy. a. Resident 3 was not provided a water pitcher b. Resident 5 was not provided a water pitcher c. Resident 45 was not given 200 milliliters ([ml] unit of measurement) of water, as ordered, after administration of Glucerna (a nutritional supplement meal replacement designed for residents with diabetes [a condition whereby the body is not able to regulate blood levels of sugar]) via gastrostomy tube (G-tube, surgical procedure wherein a tube is inserted through the abdomen wall and into the stomach used for nutrition and medication administration) on 10/31/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they do not have a medication error rate of five percent (%) or greater as evidenced by the identification of eleven (11) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturers specifications (not recommendations) regarding the preparation and administration of the medication or biological; accepted professional standards and principles which apply to professionals providing services) out of 25 opportunities (observed administered medications) for error and yielded a facility medication error rate of 44 percent for five out of 23 sampled residents (Residents 9, 16, 41, 45, and 48) observed during medication administration (med pass). Licensed Vocational Nurse (LVN 1) failed to administer: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors by failing to administer 10 medications on 10/31/2023 according to the physician's order for five (5) of 11 residents observed for medication administration (Residents 9, 16, 41, 45, and 48). 1. Late administration of Metoprolol Tartrate (a medication used to treat high blood pressure) 50 milligrams (mg-a unit of measure for mass) for Resident 9. 2. Late administration of Metformin (a medication used to treat high blood sugar levels caused by type 2 diabetes) 850 mg for Resident 48. 3. Late administration of Carvedilol (a medication that slows down the heart rate making it easier for the heart to pump blood around the body) 25 mg and Metformin 1000 mg for Resident 16. 4. Late administration of Carvedilol 3.125 mg for Resident 41. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and dispose medication for one of one medication storage room in accordance with the facility's policy and procedure. There were four (4) medications observed stored in the medication storage room with past the expiration date. In addition, there were 4 bottles of medications/ supplements that were stored in the Director of Nursing's (DON) office. These deficient practices had the potential to cause inaccurate test results when expired blood sugar strips are used, medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturers specifications [not recommendations] regarding the preparation and administration of the medication or biological; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the diet menu instructions when serving lunch for two of four sampled residents. (Residents 45 and 61). This had the potential for the residents not to receive the required amount of nutrition as indicated on the therapeutic diet (a meal plan that controls the intake of certain foods or nutrients in the treatment or management of certain diseases, illnesses, or medical conditions) menu, which could lead to weight loss or gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label foods in the kitchen with item names, open date, and expiration date and discard expired food as indicated on the facility policy. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity and respect for one of 23 sampled residents (Resident 24). The facility staff was observed standing above Resident 24's eye level while assisting the resident during mealtime. This deficient practice had the potential to affect Resident 24's self-esteem and self-worth and violates Resident 24's right to be treated with dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device (a device used by a resident to signal his or her need for assistance) was within reach for one of 23 sampled residents (Resident 69) who had a history of cerebrovascular accident (CVA, stroke- loss of blood flow to a part of the brain) and left sided weakness. This deficient practice had the potential to negatively impact the psychosocial well-being of Resident 23 and result in delayed provision of care and services.

Inspectors wroteBased on interview and record review, the facility failed to provide quarterly statement of funds per policy and procedure for one of one sampled resident (Resident 3). This deficient practice had the potential to result in Resident 3 being worried about how much money was in his account and potential for misappropriation of funds.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or resident representatives for two (2) of nine (9) sampled residents (Resident 23 and 30). This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on interview and record review, the facility failed to notify the State Long Term Care Ombudsman (public advocate) of the resident's transfer from the facility to the General Acute Care Hospital (GACH) for one (1) of 1 sampled resident (Resident 30). This deficient practice had the potential to result in the State Long Term Care Ombudsman not being aware of the resident's transfer and condition and inappropriate resident discharge or transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized baseline care plan with 48 hours of admission to meet the immediate needs that included interventions for safety and preferences for one of 23 sampled residents (Resident 69) who had left-sided hemiplegia (paralysis of one side of the body). This deficient practice had the potential to negatively affect the well-being and the delivery of necessary care and services for Resident 69.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive and resident-centered care plan for two of 23 sampled residents (Residents 45 and 69) as indicated on the facility policy and procedure. 1. Resident 45's Care Plan did not indicate complete interventions to prevent falls. 2. Resident 69 did not have a care plan for left-sided hemiplegia (paralysis of one side of the body. These deficient practices had the potential for Resident 45 and Resident 69 to not be appropriately cared for by facility staff in providing resident-centered care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functioning television remote control for one of 23 sampled residents (Resident 64) to support her choice of activity based on the comprehensive assessment. This deficient practice resulted in Resident 64 not able to watch television from 10/27/2023 to10/30/2023, which is a part of her preferred activity and had the potential to affect Resident 64's sense of self-worth and psychosocial well-being and meaningfulness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer/injury (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure sores designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for one of one sampled resident (Resident 3) in accordance with the facility's policy. This deficient practice had the potential to place the Resident 3 at risk for skin integrity complications and pressure injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe environment for one (1) of six (6) sampled residents (Resident 57), a fall risk resident, when Resident 57's bed was observed not in the lowest position. Resident 57 did not have a fall risk signage inside the room per facility policies and procedures. This deficient practice had the potential for Resident 57 to sustain an injury in an event of a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident with a gastrostomy tube (GT, a tube that is passed through the abdominal wall to the stomach used to provide nutrition) received tube feeding as indicated on the physician's order for one (1) of five (5) sampled residents (Resident 23). This deficient practice had the potential to result in Resident 23 to not receive the volume of tube feeding formula ordered, which can lead to weight loss, malnutrition (lack of sufficient nutrients in the body), and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure a coordination of care between facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for one of one sampled resident (Resident 54) in accordance with the facility's hospice policy and hospice agreement by failing to ensure: a. a hospice comprehensive assessment to include a documented evidence of hospice staff notes visits on 10/25/2023, and 10/28/2023. b. hospice care plan was revised This deficient practice had the potential for Resident 54 not to receive the hospice care and services necessary to promote comfort and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control measures for three (3) of three (3) sampled residents (Residents 16, 41 and 45), when: 1. Cleaning of the manual blood pressure monitor (an instrument for measuring blood pressure), was not done prior to use for Resident 16. 2. Cleaning of the blood pressure cuff (attached to the manual blood pressure monitor) was not done between each use for Residents 41 and 45. 3. Purified water was not used to flush the gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach), per policy, for Resident 45. These deficient practices had the potential to spread infection through pathogens (organisms or agents that can produce disease) to Residents 16, 41, and 45 by using an unclean blood pressure cuff, and using unfiltered water in Resident 45's g-tube.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the recent (last survey was 11/04/2022) survey reports (outcome of the survey that were conducted to protect residents and to ensure that all residents receive the quality of care) are accessible for all the residents. This deficient practice had the potential for the residents and their legal representatives to not be fully informed of the facility's deficient practices and how they were corrected.

Inspectors wroteBased on observation and record review, the facility failed to ensure two (2) of 27 rooms (13 and 14) accommodated no more than four residents in each room. rooms [ROOM NUMBERS] have five residents and five beds. This deficient practice has the potential for the resident's care and services to not be adequately accommodated, have an adverse effect on the residents' safety, affect provision of care and services, and place residents at risk for lack of privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the minimum of 80 square feet (sq.ft.) per resident bed in 25 of 27 residents' rooms in the facility. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.