Saint Vincent Rehabilitation & Nursing Center

Inspectors wroteBased on record review, and interview, it was determined that the facility failed to ensure that a resident receiving psychotropic medications received a gradual dose reduction (GDR) for 1 out of 5 residents reviewed for unnecessary medications in a final sample of 16 residents. (Resident identifier is #2.)

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that a resident with a pressure ulcer had necessary treatment and services, which included documentation of weekly assessments that contained measurements and descriptions of the pressure ulcer for 1 out of 3 residents reviewed for pressure ulcers (Resident Identifier is #29).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to obtain physician's orders for oxygen for 1 of 1 residents reviewed for respiratory care in a final sample of 16 residents (Resident identifier is #54).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for Transmission Based Precautions (TBP) to prevent the potential spread of infection for 1 of 1 residents reviewed for TBP in a final sample of 16 residents. (Resident identifier is #44.)

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that residents were offered the COVID-19 vaccine or provided education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine for 4 of 5 residents reviewed for immunizations (Resident Identifiers are #22, #29, #36, and #39).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was informed, in writing, the items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services for 2 of 3 residents reviewed for Beneficiary Notices who remained in the facility (Resident identifiers are #44 and #45).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 7 of 92 days reviewed between October 1, 2023 and December 30, 2023.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to follow antibiotic use protocols related to the appropriate use of antibiotic monitoring, tracking, and reviewing antibiotic use for 6 of 12 months reviewed for antibiotic use.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 3 of 3 residents reviewed for activities (Resident Identifiers are #45, #55, and #63).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure residents were offered and/or provided education on the risks and benefits of the Pneumococcal or Influenza Vaccination for 2 of 5 residents reviewed for vaccinations (Resident Identifiers are #29 and #59).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was informed timely of the Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN) for 2 out of 3 residents reviewed for beneficiary notices (Resident Identifiers are #5 and #65).

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the required committee members attended meetings at least quarterly for 2 of the 4 quarterly meetings reviewed.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide sufficient staffing numbers to meet the residents' needs for 12 out of 32 days reviewed.

Inspectors wroteBased on observation, interview, and policy review it was determined that the facility failed to ensure that medications were labeled and stored in accordance with the manufacturer's instructions for 2 of 4 medication carts observed (Resident identifiers are #1, #2, and #3).

Inspectors wroteBased on observation and interview, it was determined the facility failed to follow Centers for Disease Control and Prevention (CDC) guidelines for conducting COVID-19 testing for 1 of 1 unit observed.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the daily nurse staffing data was posted for 25 of the 30 days reviewed.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to follow the Center for Disease Control and Prevention's (CDC) return to work guidelines for healthcare personnel (HCP) who were positive for COVID-19 and failed to implement a system for surveillance to monitor all staff who had worked and tested positive for COVID-19 for 8 of 10 healthcare personnel reviewed for COVID-19 infection. Findings Include: Review on 9/6/23 of the CDC's Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 [Severe acute respiratory syndrome coronavirus 2] Infection or Exposure to SARS-CoV-2, updated September 23, 2022, revealed, . Return to Work Criteria for HCP [Health Care Personnel] with SARS-CoV-2 Infection. HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 10 of 90 days reviewed for Quarter 2 (January 1 - March 31, 2023).

Inspectors wroteBased on observation, interview, and policy review it was determined that the facility failed to label, date, and store food in accordance to professional standards in the main kitchen and in 2 of 3 kitchenettes observed and failed to monitor the dishwasher temperature to ensure proper temperatures were achieved.

Inspectors wroteBased on observation, interview, and review of the facility's policy and procedure it was determined that the facility failed to ensure expired medications were removed on 1 of 3 medication carts and 1 of 2 medication storage rooms observed (Resident Identifier is #53).

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to maintain patient equipment (oxygen filter) for the use of oxygen for 2 of 2 residents reviewed for respiratory care in a final survey sample of 23 residents (Resident identifiers are #19 and #30).

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to update or post the daily nurse staffing data since 5/19/23.