Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Saint Vincent Healthcare during CMS and state inspections, most recent first.
Failure to Maintain Eye-Level Dignity During Mealtime Assistance: Staff assisted three residents with meals without being at eye level. Two CNAs were observed feeding residents while standing or sitting on a bar stool with the beds in the lowest position, and a CNA confirmed staff should have raised the bed or used a lower chair to promote dignity. The residents had significant cognitive impairment and required partial/moderate assistance with eating, with diagnoses including dementia, malnutrition, dysphagia, and mood disorders.
A resident with severe cognitive impairment and fall risk and another resident with dementia, mobility issues, fall risk, and wandering risk were involved in deficient supervision and safety practices. Housekeeping was observed mopping a room while both residents were present in bed, and the DON, QAN, and HKS stated residents should not be in the room during mopping. The wandering resident was also observed entering other residents' rooms and the DON's office without staff nearby to reorient or redirect the resident.
A resident’s name, room number, and post-op wound care instructions were posted outside the room, exposing confidential clinical information. The resident had recent hand surgery and diagnoses including atrial fibrillation, glaucoma, and macular degeneration, with moderately impaired cognitive skills noted on the MDS. RNS stated the information was confidential and should have been filed in the chart, and the DON stated resident information should not be openly posted where it could be seen by visitors or staff not directly involved in care.
Failure to complete PASRR screening after readmission. A resident with major depressive disorder, anxiety disorder, and severe cognitive impairment was readmitted without a new PASRR 1 being completed. The DON stated the new PASRR should have been done because of the resident’s new mental health diagnoses, and RN staff were expected to verify whether a hospital PASRR was available and review it per facility policy.
Failure to Monitor and Report Left Eye Redness: A resident with cicatricial ectropion and severe cognitive impairment had left eye redness noted by staff, but the care plan-directed monitoring and documentation were not found in the nurses’ notes. An AAS and the AD each observed the redness but did not report it to nursing, and the MDSN and DON stated the resident’s eye redness should have been monitored and communicated per the care plan.
Failure to Monitor and Document Fluid Restriction for a Dialysis Resident A resident with ESRD and dependence on dialysis had a physician-ordered 1000 ml/day fluid restriction, but staff did not accurately monitor or document all fluid intake. The resident was observed drinking tea, drinking water from a lunch bottle, and keeping a 1-liter water container at the bedside, while staff were unsure how much was consumed and did not consistently record intake. Facility leaders stated the resident’s fluid intake was not properly monitored and documented, and the fluid restriction policy was not followed.
Failure to Administer Ordered Supplements: An LVN did not follow physician orders during a med pass by giving ferrous sulfate on the wrong day and omitting daily Vitamin C for a resident with anemia, malnutrition, and dementia. The DON stated the supplements worked concurrently and should have been administered as ordered, and the facility P&P for medication administration was not followed.
Uncovered and Overflowing Outdoor Trash Bins: The facility failed to keep the outdoor garbage area free of litter when a black trash bin was not fully closed and a grey trash bin had no lid and was overflowing with garbage. Boxes and PPE trash bags were left on the ground next to the bin. The Kitchen staff and MS stated trash should not be left on the ground, bins should not be overfilled, and garbage containers should remain closed when not in use.
A resident with COPD and dementia had hospice orders for SN, HCA, MSW, and clergy visits, but the hospice binder showed missed visits and lacked hospice notes for multiple disciplines. The resident was unsure whether HCA visits occurred, and RNS, LVN, and the DON stated hospice staff were not following the schedule and that licensed staff should have checked the binder and coordinated with hospice staff to verify visits and care delivery.
Five-bed rooms were observed in two areas of the facility, with one room holding four occupied beds and one vacant bed and the other room holding five occupied beds. The rooms were reviewed along with the facility's room waiver request, which stated the rooms met residents' special needs and allowed safe evacuation, but the deficiency remained that the rooms exceeded the allowed occupancy limit.
Insufficient Resident Room Square Footage: The facility failed to provide at least 80 sq ft per resident in 25 of 27 rooms. Surveyors observed that residents, including those who were ambulatory and wheelchair bound, could move about their rooms without difficulty, and a resident interviewed stated she had enough space and that nurses could assist her without problems. Record review showed multiple multi-bed rooms below the minimum square footage requirement, and the facility’s waiver request acknowledged that rooms 1 through 9 and 11 through 26 were under the required size.
The facility failed to follow proper food handling practices, including improper storage of frozen meats, unlabeled and improperly sealed dry pasta, and expired food items in the kitchen. These deficiencies were observed during a kitchen inspection, with the Dietary Service Supervisor acknowledging the importance of adhering to storage protocols to prevent contamination and potential illness among the 67 residents consuming food by mouth.
The facility failed to keep two dumpsters in the parking lot closed and free from overflowing trash, contrary to its policy. During an inspection, the Maintenance Supervisor and Assistant observed that the dumpsters were overflowing, preventing the lids from closing. The facility's policy requires lids to remain closed to deter pests. A review of the policy confirmed that trash should be packed down, boxes folded, and lids closed when not in use.
The facility failed to implement enhanced barrier precautions (EBP) for 11 residents, as required by their policy, to prevent the spread of multidrug-resistant organisms (MDROs). Staff did not consistently wear gowns during high-contact care activities, and there was a lack of signage and PPE availability outside residents' rooms. This deficiency placed residents at a higher risk for cross-contamination and increased the spread of infection.
A resident with Parkinson's disease and other conditions was observed with an uncovered urinary catheter bag, contrary to the facility's policy requiring dignity bags. Staff interviews confirmed the policy's importance for maintaining dignity and self-esteem, highlighting a deficiency in adhering to these standards.
A resident with hand contractures and limited mobility was not provided with an appropriate call light device, relying instead on verbal calls for assistance. Despite facility policies emphasizing the need for adaptive devices, the resident was given a standard call cord, which she could not use. Staff confirmed the resident's inability to use the call cord, highlighting a failure to accommodate her needs.
A resident with chronic kidney disease, urinary retention, dementia, and gross hematuria had a care plan that included inappropriate interventions, such as providing fluids via a PEG tube, despite the resident not having one. Additionally, the care plan included cranberry use for UTI prophylaxis without an order. These discrepancies were identified by an RN, highlighting a failure to ensure the care plan was resident-centered and based on accurate data.
A resident was diagnosed with schizophrenia without proper evaluation by a Medical Doctor, leading to a potential provision of unnecessary care. The resident, initially admitted with dementia and other conditions, was prescribed Seroquel for aggressive behavior. The CNP added the schizophrenia diagnosis based on staff reports, without documenting delusions or consulting the resident's family. Observations showed no symptoms of schizophrenia, and the DON noted the diagnosis was inconsistent with the resident's history.
A resident with reduced mobility and Parkinson's disease was not provided necessary assistance during meals, as required by their care plan. Observations showed the resident struggling to eat, resulting in food spillage, and interviews confirmed the resident's preference for assistance over using a plate guard. The facility's policies on daily living activities and accommodation of needs were not followed, leading to this deficiency.
A resident with a stage 3 pressure injury on the right heel did not receive the prescribed wound care treatment from October 1 to October 7. The resident, with severe cognitive impairment and multiple health conditions, required specific wound care that was not followed due to discrepancies between the physician's order and the wound care physician's progress note. Nursing staff acknowledged the failure to implement the correct treatment plan, which was essential for proper wound care and healing.
A resident receiving gastrostomy tube feeding was observed with the head of bed (HOB) less than 30 degrees, contrary to the facility's policy requiring 30 to 45 degrees elevation to prevent aspiration. The resident, with dysphagia and severe cognitive impairment, was dependent on assistance for daily activities. Both the LVN and DON confirmed the necessity of HOB elevation during feeding.
A facility failed to provide trauma-informed care for a resident with PTSD, as staff were unaware of the resident's diagnosis and triggers. The resident had informed staff about his PTSD triggers, but there was no care plan in place. The Social Services Director confirmed the lack of reassessment and care planning upon the resident's readmission, contrary to the facility's policy.
A facility failed to verify the competency of a Registry Certified Nursing Assistant (RCNA) before they provided care to residents. The Director of Staff Development did not check or request documentation of the RCNA's skills or certification, relying only on verbal confirmation from the registry. The Director of Nursing acknowledged the importance of knowing staff competencies for resident safety, but the facility lacked documentation. This oversight had the potential to compromise resident care and safety.
A resident was administered Risperdal without a clinical justification, as there was no diagnosis of schizophrenia, which the medication is intended to treat. The facility's DON and RN acknowledged the lack of evidence for the diagnosis, and the facility's policy requiring evaluation of antipsychotic medication use was not followed. This resulted in the unnecessary use of Risperdal, contrary to the facility's guidelines.
A resident with severe cognitive impairments and specific food preferences, including Mexican food, was not provided with their requested meals on multiple occasions, despite these preferences being documented in their care plan. The facility's failure to honor these preferences led to the resident refusing meals, as observed in the Daily Meal Eating Log. Interviews with staff revealed a lack of awareness and documentation regarding the resident's preferences, and the facility's policy on accommodating resident needs was not followed.
A facility failed to offer the pneumococcal vaccine to a resident upon readmission, as required by its policy. The resident, with a history of ventricular tachycardia, Parkinson's Disease, and major depressive disorder, had previously refused the vaccine but was not offered it again during the current admission. Interviews with the DON and IPN confirmed the lapse in protocol, and the resident expressed interest in receiving the vaccine, citing a history of pneumonia.
The facility failed to meet the minimum square footage requirements for resident rooms, affecting 25 out of 27 rooms. Despite this, residents and staff reported no issues with space for care and movement. A waiver was recommended for the affected rooms.
Failure to Maintain Eye-Level Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to provide care in a manner that maintained dignity and respect for three sampled residents by not ensuring staff were at eye level while assisting them with meals. Resident 3 was admitted and readmitted with diagnoses including protein calorie malnutrition, dementia, and major depressive disorder. The MDS dated 10/28/2025 indicated severely impaired cognitive skills for daily decision making, partial/moderate assistance with eating, substantial/maximal assistance with oral hygiene and upper body dressing, and dependence for toileting hygiene, lower body dressing, and footwear. During an observation in Resident 3's room on 11/18/2025 at 12:39, CNA 1 was observed talking to Resident 3, who had stopped eating her food, and then feeding the resident while standing. CNA 1 was not at eye level with Resident 3. Resident 57 was admitted and readmitted with diagnoses including protein calorie malnutrition, dysphagia, dementia with psychotic disturbance, and schizoaffective disorder. The MDS dated [DATE] indicated severely impaired cognitive skills for daily decision making, partial/moderate assistance with eating, substantial/maximal assistance with upper body dressing, and dependence for oral, toileting, and personal hygiene, showering/bathing, lower body dressing, and footwear. During an observation in Resident 57's room on 11/18/2025 at 12:33 PM, CNA 1 was assisting Resident 57 with lunch while sitting on a bar stool, and the resident's bed was in the lowest position; CNA 1 was not at eye level with the resident. Resident 65 was admitted with diagnoses including vitamin D deficiency, dementia with mood disturbance, and major depressive disorder. The MDS dated [DATE] indicated severely impaired cognitive skills for daily decision making, partial/moderate assistance with eating, and dependence for oral, toileting, and personal hygiene, showering/bathing, upper and lower body dressing, and footwear. During an observation in Resident 65's room on 11/18/2025 at 12:25 PM, CNA 2 was assisting Resident 65 with lunch while sitting on a bar stool, with the bed in the lowest position, and CNA 2 was not at eye level with the resident. CNA 3 later confirmed that CNA 1 and CNA 2 were not at eye level with Residents 57 and 65 while assisting with lunch and stated staff could raise the bed or use a lower chair or stool to achieve eye level in accordance with the facility's dignity policy.
Failure to Prevent Accidents During Housekeeping and Wandering
Penalty
Summary
The facility failed to provide necessary care and intervention to prevent accidents or injury for two residents in the Accidents care area. Resident 4 had diagnoses including lack of coordination and a history of falls, and the MDS indicated severe impairment in cognitive skills for daily decision making, along with assistance needs for toileting, showering, dressing, hygiene, and eating. Resident 4's care plan identified the resident as at risk for falls related to poor safety awareness and a history of falls, with an approach to keep the environment free of hazards and maintain a safe environment at all times. Resident 20 had diagnoses including muscle weakness, abnormalities in gait and mobility, and dementia. The MDS indicated moderate impairment in cognitive skills for daily decision making and assistance needs with showering, toileting, hygiene, dressing, and eating. Resident 20's care plan identified risk for falls related to poor safety awareness and mobility, with an approach to keep the environment free of hazards and maintain a safe environment at all times, and also identified risk for wandering and elopement with an approach to gently redirect the resident back to supervised areas. On 11/18/2025, housekeeping was observed mopping the floor in Room A while both residents were in bed and a wet floor precaution sign was placed by the door. On 11/20/2025, Resident 20 was observed wandering in another resident's room without staff following and redirecting the resident, and on 11/21/2025 the resident was observed entering the DON's office where surveyors were present without facility staff nearby. Staff interviews stated residents should not be in the room while mopping is occurring and that residents who wander should be reoriented, redirected, and guided back to supervised areas.
Resident information posted outside room
Penalty
Summary
Facility staff failed to keep Resident 48’s personal and medical information private and confidential when the resident’s name, room number, and post-op wound care instructions were posted outside the resident’s room. Resident 48 was admitted with diagnoses including unspecified atrial fibrillation, unspecified glaucoma, and unspecified macular degeneration, and the MDS dated 6/3/2025 indicated moderately impaired cognitive skills for daily decision making and assistance needs with multiple activities of daily living. The resident had surgery on the left hand on 11/17/2025, and the physician order summary included post-operative wound care instructions for the closed wound. During observation on 11/18/2025, a sheet of paper with Resident 48’s identifying information and wound care instructions was seen posted outside the room. RNS 1 stated the instructions were confidential, should not have been posted outside the door, should have been filed in the chart, and should only have been given to staff providing direct care. The DON stated resident information should be protected and not posted where it could be seen by visitors or staff not directly involved in care, and the facility policy stated confidential clinical information should be protected and clinical status or care needs should not be openly posted unless specifically requested by the resident or family member.
Failure to Complete PASRR Screening After Readmission
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not completed for one sampled resident, Resident 4, after readmission to the facility. The resident’s admission record showed diagnoses that included major depressive disorder and anxiety disorder. The resident’s MDS dated 10/1/2025 indicated severe impairment in cognitive skills for daily decision making and showed the resident required varying levels of assistance with toileting, showering, dressing, hygiene, and eating. During interview, the DON stated a new PASRR 1 should have been completed on readmission because of the resident’s new diagnoses of major depressive disorder and anxiety disorder, and stated no PASRR 1 had been completed. The DON also stated admission personnel were responsible for ensuring the hospital file exchange was obtained and that the PASRR website was checked for a downloaded PASRR. RN 2 stated licensed staff should have checked the resident’s medical records for a PASRR from the hospital. The facility’s PASRR policy stated that when a resident is newly admitted after a hospital stay, staff will review the hospital-completed PASRR, and if there is a significant change since the hospital PASRR was completed, a resident review will be completed.
Failure to Monitor and Report Left Eye Redness
Penalty
Summary
The facility failed to ensure monitoring and care were provided for a resident’s left eye redness in accordance with the care plan and facility policy. The resident was admitted and later readmitted with a diagnosis of cicatricial ectropion of the left eye and had severe cognitive impairment. The care plan, revised on 10/12/2025, identified the resident as at risk for eye redness, irritation, and infection and directed staff to notify the MD for signs and symptoms of eye infection, including redness. During observation on 11/18/2025, the resident was lying in bed and had redness on the left lower eyelid. Review of the nurses’ progress notes showed no documentation of monitoring for the left eye redness. The MDS Nurse stated staff should monitor and notify the MD for the resident’s left eye redness to prevent the condition from worsening. An Assistant Activity Staff member stated he noticed the redness a couple of days earlier but assumed the resident was already receiving treatment and did not notify staff. The Activity Director stated she also did not notify nursing because she believed the redness had always been present and thought nursing was aware. The DON stated nursing staff should follow the care plan intervention to monitor the resident’s left eye for redness and staff should not assume treatment had already been given.
Failure to Monitor and Document Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to provide safe, appropriate dialysis-related care for a resident with end stage renal disease, dependence on renal dialysis, acute respiratory failure with hypoxia, and pleural effusion. The resident’s record showed a physician order for a 1000 ml fluid restriction per 24 hours, with specific amounts allotted for meals, nursing, and a Nepro supplement. The care plan also directed staff to monitor intake and output every shift because the resident was at risk for complications related to fluid fluctuations. During observation, the resident was seen drinking tea in the dining room and later had a 240 ml water bottle and a 1 liter water container at the bedside. The resident stated he poured leftover water from his sack lunch into his own water container and said staff did not ask how much he drank from it each shift. The resident also drank part of a cup of water from his lunch tray. RNA 1 stated she gave the resident tea but did not document how much was consumed, and she was unsure of the resident’s fluid allowance per shift. LVN staff stated the intake and output record was used to document only some fluids, and there was uncertainty about whether CNA documentation captured all of the resident’s intake. Review of the Self Care Log showed documented fluid amounts that exceeded the ordered restriction on at least one day, and QAN stated the resident’s fluid intake was not accurately monitored or documented. QAN and LVN staff stated residents on fluid restriction were not allowed to have water pitchers at the bedside, and the resident should not have had his own water container there. The DON stated the resident’s fluid intake should have been closely monitored and documented, and that the facility’s fluid restriction policy was not followed.
Failure to Administer Ordered Supplements
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of one resident when ordered medications were not administered as prescribed. The resident was admitted and later readmitted with diagnoses including anemia, moderate protein-calorie malnutrition, and dementia. The MDS dated 9/1/2025 indicated the resident had severely impaired cognitive skills for daily decision making and required assistance with several activities of daily living, including eating, oral/personal hygiene, dressing, toileting hygiene, bathing, transfers, and walking. The resident had physician orders for ferrous sulfate 325 mg by mouth every other day for anemia and Vitamin C 500 mg by mouth daily as a supplement. During observation of the medication pass, the LVN administered ferrous sulfate but did not administer Vitamin C. During interview, the LVN stated the resident had last received ferrous sulfate the day before and that the dose given during the med pass was not due until the following day; the LVN also stated Vitamin C was omitted during the med pass. The DON stated ferrous sulfate worked concurrently with Vitamin C and should be administered as ordered by the physician, and stated the facility's P&P for administering medication as ordered by the physician was not followed.
Uncovered and Overflowing Outdoor Trash Bins
Penalty
Summary
The facility failed to maintain a debris-free dumpster area when trash was not properly contained, uncovered, and overflowing in two of five trash bins. During observation in the outdoor garbage area, there were two dumpsters, one grey trash bin, one black trash bin, and three green trash bins; the black trash bin was not completely closed, and the grey trash bin beside it had no lid and was overflowing with garbage. Folded brown boxes and trash bags filled with PPE were also on the ground next to the grey trash bin. The Kitchen [NAME] stated trash should not be left on the ground and that ants, cockroaches, and flies can enter uncovered trash and get inside the facility. The Maintenance Supervisor also observed trash overflowing from two trash bins and stated trash bins should not be overfilled and should be kept closed when not in use. The facility policy titled, Food-Related Garbage and Refused Disposal, dated October 2017, stated outside garbage containers must have tight-fitting lids that remain closed when not in use and be free of surrounding litter.
Missing Hospice Visit Documentation and Coordination
Penalty
Summary
The facility failed to ensure there was documented evidence of hospice service visits and coordination in the medical record for one resident receiving hospice care. The resident was admitted with COPD and dementia, and the MDS dated 10/9/2025 showed moderate impairment in cognitive skills for daily decision making, dependence with showering, substantial/maximal assistance with toileting, lower body dressing, and footwear, partial/moderate assistance with oral and personal hygiene and upper body dressing, and supervision with eating. During observation and interview, the resident stated he was unsure whether HCA visits occurred twice a week and said he would not know if they visited because they did not tell him they were from hospice. Review of the hospice plan of care showed ordered SN, HCA, MSW, and clergy visits, but the hospice binder showed missed SN and HCA visits across October and November, no clergy visits, and no hospice notes for November from SN, HCA, or MSW. RNS, LVN, and the DON stated hospice staff were not following the scheduled visits, the binder lacked documentation of visits and services provided, and licensed staff and supervisors should have checked the hospice binder and coordinated with hospice staff to verify visits and care delivery.
Five-Bed Resident Rooms Exceeded Allowed Occupancy
Penalty
Summary
The facility failed to ensure that two of 27 rooms accommodated no more than four residents in each room. During the initial tour, rooms 13 and 14 were observed with five beds each, and both rooms were identified as having five-bed occupancy arrangements. Room 13 had four occupied beds and one vacant bed, while room 14 had all five beds occupied. The report states that the residents in these rooms did not complain about the space, and that there was enough room for staff to provide care, enough storage for belongings, and space for beds, side tables, dressers, and resident care equipment. A review of the facility's room waiver showed that rooms 13 and 14 each had 5 beds and square footage of 357.19 and 356.25, respectively, with 71.44 and 71.25 square feet per bed. The facility's room waiver letter requested continued waivers for these rooms, stating that the rooms were in accordance with the special needs of the residents, did not adversely affect residents' health and safety or impede their ability to attain highest practicable well-being, and that residents could be quickly and safely evacuated in an emergency. The department indicated it would recommend the room waiver for these rooms.
Insufficient Resident Room Square Footage
Penalty
Summary
The facility failed to provide the minimum of 80 square feet per resident bed in 25 of 27 resident rooms. During observation of resident rooms 1 through 9 and 11 through 26, surveyors found that 25 rooms did not meet the minimum square footage requirement per resident. The residents did not complain about the space in their rooms, and there was enough space for staff to provide care and enough storage for residents' belongings. Residents who were ambulatory and wheelchair bound were able to move in and out of the rooms without difficulty. During a concurrent observation and interview in one resident's room, the resident was seen resting in bed, then walking to the closet and back to bed, and stated she could move about the room without difficulty, had her own bed, table, and closet, and that nurses were able to help her without problems. A CNA also stated there was enough space in the residents' rooms to provide care and that staff could move a recliner chair in and out of the room without issues. Record review showed multiple rooms with square footage per resident below 80 square feet, including rooms with 2, 3, or 5 beds, and the facility's room waiver request acknowledged that rooms 1 through 9 and 11 through 26 measured less than the minimum requirement for room size.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as outlined in their policies and procedures, which could potentially lead to foodborne illnesses among the 67 residents consuming food by mouth. During an observation in the kitchen, it was noted that frozen food items, such as sliced bacon and frozen meat, were not stored in airtight, moisture-resistant wrappers as required by the facility's policy. Instead, the kitchen staff only folded the flaps of the original boxes, which the Dietary Service Supervisor incorrectly stated was sufficient. Additionally, dry pasta was improperly stored; a bag of twisted pasta was ripped and not sealed, and a bag of egg noodles was neither labeled nor dated, contrary to the facility's procedures for dry storage. Further inspection revealed expired food items in the kitchen, including Worcestershire sauce, peanut butter, baking soda, and a package of seasoning with an unreadable expiration date. The Dietary Service Supervisor confirmed that opened food items should be labeled with the date they were opened and a use-by date, and expired items should be discarded. The facility's policy mandates that all food items in storage must be labeled and dated, and opened items should be used by the date following storage guidelines. The failure to follow these protocols was acknowledged by the Dietary Service Supervisor, who emphasized the importance of proper storage to prevent contamination and potential illness among residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that two garbage containers (dumpsters) in the parking lot had their lids closed and were not overflowing with trash, as per the facility's policy. During an observation and interview with the Maintenance Supervisor and Maintenance Assistant, it was noted that the dumpsters were overflowing with trash, causing the lids to remain open. The Maintenance Assistant acknowledged the issue, stating that the trash was overflowing and the lids could not be closed. The Maintenance Supervisor confirmed that the facility's policy required dumpster lids to remain closed to prevent pests such as rodents, flies, and insects from being attracted to the dumpsters and potentially entering the facility. A review of the facility's Policy and Procedure on Exterior Maintenance indicated that garbage and trash containers should be maintained in a clean and pest-free condition, with trash packed down, boxes folded, and lids closed when not in use.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for 11 residents, as required by their policy, to prevent the spread of multidrug-resistant organisms (MDROs). This deficiency was observed through various instances where staff did not wear the appropriate personal protective equipment (PPE) such as gowns during high-contact care activities. For example, a Licensed Vocational Nurse (LVN) did not wear a gown while administering medications through a gastrostomy tube (GT) for a resident, and a Certified Nurse Assistant (CNA) did not wear a gown while changing a resident's diaper. Additionally, there was a lack of signage and PPE availability outside the rooms of residents on EBP. The facility's policy indicated that EBP should be implemented for residents with wounds, indwelling catheters, and feeding tubes, regardless of their MDRO status. However, observations revealed that the facility did not adhere to this policy. For instance, there were no EBP signs or PPE carts outside the rooms of residents who required them, and staff members were not consistently using gowns during high-contact activities. Interviews with staff, including the Infection Prevention Nurse (IPN), revealed a misunderstanding of when EBP should be applied, with some staff believing it was only necessary for residents with current infections. The failure to implement EBP as per the facility's policy placed residents at a higher risk for cross-contamination and increased the spread of infection. The facility's policy clearly outlined the need for gowns and gloves during specific high-contact activities, yet these measures were not consistently followed. This lack of adherence to infection control protocols was evident in multiple instances across the facility, highlighting a systemic issue in the implementation of EBP and the availability of necessary PPE.
Failure to Use Dignity Bag for Resident's Catheter
Penalty
Summary
The facility failed to ensure that a foley catheter was covered with a dignity bag for one resident, which is a violation of the resident's right to a dignified existence. The resident, who was admitted with diagnoses including Parkinson's disease, muscle wasting, atrophy, and polyneuropathy, was observed with an uncovered urinary catheter bag. The resident's Minimum Data Set indicated moderately impaired cognitive skills and a need for substantial assistance with daily activities, including toileting. Despite the resident's capacity to understand and make decisions, as noted in their Initial History & Physical, the facility did not adhere to its policy requiring dignity bags for catheter bags. Interviews with facility staff, including a Treatment Nurse and the Director of Nursing, confirmed that the facility's policy mandates the use of dignity bags to maintain residents' dignity and self-esteem. The facility's Policy and Procedure on Dignity, revised in February 2021, emphasizes the importance of treating residents with dignity and respect, prohibiting practices that compromise dignity. The failure to cover the catheter bag as per policy was identified as a deficiency that could potentially impact the resident's self-worth and self-esteem.
Failure to Provide Accessible Call Light for Resident with Physical Limitations
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 63, by not providing an appropriate call light device. Resident 63 was admitted with several diagnoses, including left hand contracture, pain in the right shoulder, weakness, and major depressive disorder. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and functional limitations in both upper extremities, requiring substantial assistance with daily activities. Despite these limitations, the resident was provided with a standard call cord, which she was unable to use due to her hand contractures. Observations and interviews revealed that Resident 63 was unaware of the call cord's presence and unable to reach or use it effectively. Staff members, including Certified Nursing Assistants (CNAs) and a Registered Nurse (RN), confirmed that the resident had restricted movement in her arms and hands, making it difficult for her to use the call cord. Instead, the resident relied on verbally calling for assistance or waiting for staff to check on her during regular rounds. The RN acknowledged that Resident 63 had not been evaluated for a more suitable call light device, such as a pad call light, which could accommodate her physical limitations. The facility's policies and procedures emphasized the importance of accommodating residents' individual needs and preferences, including the use of adaptive devices. However, the failure to provide an accessible call light device for Resident 63 demonstrated a lack of adherence to these policies. This oversight had the potential to impact the resident's quality of care and life, as she was unable to independently call for help when needed.
Inappropriate Care Plan Interventions for a Resident
Penalty
Summary
The facility failed to ensure that the care plan for one of its residents, identified as Resident 3, was applicable and resident-centered. Resident 3 was readmitted to the facility with several diagnoses, including chronic kidney disease, urinary retention, dementia, and gross hematuria. The Minimum Data Set (MDS) assessment indicated that Resident 3 had severely impaired cognitive skills and required significant assistance with daily activities. However, the care plan included an intervention to provide fluids via a PEG tube, which was inappropriate as Resident 3 did not have a PEG tube and consumed food and liquids orally. This inappropriate intervention was acknowledged by Registered Nurse 1 (RN1) during a review. Additionally, the care plan for Resident 3 included an intervention for cranberry use as a prophylaxis for urinary tract infections, but there was no order for cranberry in the resident's records. RN1 confirmed that Resident 3 never had an order for cranberry, indicating that the care plan was not aligned with the resident's current needs. The facility's policy on comprehensive, person-centered care plans emphasizes the importance of developing care plans based on accurate data gathering and relevant clinical decision-making, which was not adhered to in this case.
Improper Schizophrenia Diagnosis Without MD Evaluation
Penalty
Summary
The licensed nursing staff at the facility failed to meet professional standards of quality by not ensuring that a resident was properly assessed and evaluated by a Medical Doctor before adding a new diagnosis of schizophrenia. The resident, who was admitted with diagnoses including dementia, major depressive disorder, and Alzheimer's Disease, was given a physician order for Seroquel to manage aggressive behavior associated with dementia. However, the diagnosis was later changed to schizophrenia without proper documentation or evaluation by a psychiatrist. The Certified Nurse Practitioner (CNP) added the schizophrenia diagnosis based on his evaluation and reports from facility staff, despite the resident's psychiatric follow-up note indicating no new symptoms or need for medication adjustment. The CNP admitted to not documenting the resident's delusions in the psychiatric follow-up note and planned to write a late entry note. The Director of Nursing confirmed that there was no documentation of communication with the resident's family to confirm the mental history or schizophrenia diagnosis, and noted that schizophrenia typically develops at a younger age. Observations of the resident showed no aggressive behavior or symptoms consistent with schizophrenia, and the resident's psychiatric condition was noted as generally unchanged. The American Psychiatric Association's guidelines indicate that schizophrenia symptoms usually appear in early adulthood and require a thorough medical examination to rule out other conditions. The facility's failure to adhere to these standards resulted in a potential provision of unnecessary care for the resident.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to provide necessary assistance to a resident with limitations in mobility, specifically during meal times, as outlined in the care plan and facility policy. The resident, who was diagnosed with reduced mobility and Parkinson's disease, had a care plan indicating the need for assistance with activities of daily living due to a right hand contracture. Despite this, observations revealed that the resident was not provided with the required assistance while eating, which was necessary to meet their nutritional needs and prevent further decline in their ability to perform daily activities. During dining observations, the resident was seen struggling to eat using only their right hand, resulting in food spillage onto their clothes and the floor. The occupational therapy notes had recommended the use of a plate guard to aid in self-feeding, but this was not utilized during the observations. Interviews with the resident and staff confirmed that the resident preferred assistance over using the plate guard and expressed dissatisfaction with the lack of help, which led to food spillage and frustration. The facility's policies on activities of daily living and accommodation of needs emphasize providing appropriate care and assistance to maintain or improve residents' abilities to perform daily tasks. However, the staff failed to adhere to these policies, as evidenced by the lack of assistance provided to the resident during meals, despite the resident's clear need for support due to their physical limitations and cognitive impairments.
Failure to Follow Wound Care Treatment Plan for Resident with Stage 3 Pressure Injury
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a stage 3 pressure injury on the right heel. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, unspecified protein-calorie malnutrition, and hyperlipidemia, was assessed as having severely impaired cognitive skills and required substantial assistance with daily activities. Despite having an order for specific wound care treatment starting on October 1, 2024, the treatment plan was not followed from October 1 to October 7, 2024. The treatment plan required cleansing with normal saline, applying collagen powder, and covering with a dry dressing, but this was not implemented as per the physician's order. Interviews with nursing staff revealed discrepancies between the treatment plan documented in the physician's order and the wound care physician's progress note. The registered nurse and treatment nurse acknowledged the inconsistency and failure to follow the wound care physician's treatment plan, which included using a wound cleanser, applying collagen, and covering with calcium alginate and bordered gauze dressing every three days. The Director of Nursing confirmed that the treatment plan should have been verified and followed to ensure proper wound care and healing, as per the facility's policy and procedure on pressure ulcers and skin breakdown.
Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
The facility failed to ensure the head of bed (HOB) was elevated at a 30-degree angle for a resident receiving gastrostomy tube (GT) feeding, as per the facility's policy. The resident, identified as Resident 28, was observed receiving GT feeding with the HOB less than 30 degrees elevation. This observation was made during a concurrent room visit and interview with LVN 1, who acknowledged that the HOB should be at least 30 to 45 degrees to prevent aspiration, which can lead to pneumonia if the resident vomits and the feeding enters the lungs. Resident 28 was initially admitted to the facility with diagnoses including dysphagia and was dependent on assistance for daily activities. The resident's care plan, initiated on 4/9/2024, indicated the need to elevate the HOB during GT feeding. The facility's policy, revised in November 2018, also required the HOB to be elevated at least 30 degrees during tube feeding to prevent aspiration. Despite these directives, the deficiency was noted during the survey, with both the LVN and the Director of Nursing confirming the requirement for HOB elevation during feeding.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, as required by their policy. The resident, who had an intact cognitive ability for daily decision-making, had previously informed staff about his PTSD triggers, which included seeing guns and violence on television. However, during interviews, both a CNA and an LVN were unaware of the resident's PTSD diagnosis and triggers, indicating a lack of communication and awareness among the staff. The Social Services Director confirmed that the resident did not have a care plan for trauma-informed care and acknowledged that the resident should have been reassessed for trauma-informed care upon readmission. The facility's policy on trauma-informed care emphasized the importance of minimizing triggers and re-traumatization through proper assessment and care planning, which was not followed in this case.
Failure to Verify Competency of Temporary Nursing Staff
Penalty
Summary
The facility failed to ensure that a Registry Certified Nursing Assistant (RCNA 1) had the necessary competencies before providing care to residents. RCNA 1 worked in the facility on a specific date without the Director of Staff Development (DSD) verifying their competency skills and certification. The DSD admitted to not having checked or requested documentation of RCNA 1's competency skills or certificate verification, relying solely on verbal confirmation from the registry. This oversight meant that the facility did not have any documentation or information regarding RCNA 1's competency skill sets before they began working. The Director of Nursing (DON) also acknowledged the importance of knowing the competency skill sets of staff to ensure proper care and resident safety. However, the facility lacked documentation of RCNA 1's competencies. The facility's policy and procedure on competency and training emphasized the need for an effective training program for all staff, including those under contractual arrangements, to ensure they possess the necessary skills to meet resident needs and ensure safety. This deficiency had the potential to result in residents not receiving appropriate nursing services and placed them at risk for injury or harm.
Unjustified Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from the unnecessary use of a psychotropic drug, specifically Risperdal, as there was no clinical justification for its use. The resident, who was initially admitted and later readmitted to the facility, had diagnoses including major depressive disorder and dementia but did not have a diagnosis of schizophrenia, which is one of the conditions Risperdal is used to treat. Despite this, the resident was prescribed Risperdal 0.5 mg twice a day upon discharge from a general acute care hospital, and this prescription was continued at the facility without proper justification. The Director of Nursing (DON) and Registered Nurse 3 (RN 3) both acknowledged that there was no evidence to support a diagnosis of schizophrenia for the resident. The DON confirmed that the resident received Risperdal without a diagnosis of schizophrenia, and RN 3 admitted to transcribing the medication order from the hospital discharge without verifying the diagnosis. The facility's policy requires that residents transferred from a hospital and receiving antipsychotic medications be evaluated for the appropriateness and indications for use, which was not adhered to in this case. The facility's policy and procedure on antipsychotic medications, revised in July 2022, clearly state that residents should not receive medications that are not clinically indicated to treat a specific condition. Despite this policy, the resident's psychiatric evaluations did not list Risperdal as a current medication, and there was no documentation of a schizophrenia diagnosis in the resident's health records. This oversight led to the unnecessary administration of Risperdal, which was not clinically justified according to the facility's own guidelines.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident, identified as Resident 68, which is a violation of the care plan and facility policy. The resident had expressed a preference for Mexican food, including tacos and beef soup, on multiple occasions. However, these preferences were not honored on specific dates, despite being documented in the resident's care plan and food preference records. This failure to provide the requested meals was observed through various records, including the resident's Speech/Language Pathology Daily Note and Dietary Progress Notes. Resident 68, who has severe cognitive impairments and requires assistance with daily activities, was admitted with diagnoses including major depressive disorder, metabolic encephalopathy, and dementia. The resident's nutritional care plan specified a mechanical soft, no added salt diet, and emphasized the importance of honoring reasonable food preferences. Despite this, the facility did not provide the requested Mexican food, leading to multiple meal refusals by the resident throughout September 2024, as documented in the Daily Meal Eating Log. Interviews with facility staff, including the Dietary Service Supervisor (DSS) and the Director of Nursing (DON), revealed a lack of awareness and documentation regarding the resident's food preferences. The DSS admitted that Mexican food was not regularly included in the menu, except on specific occasions like Cinco de Mayo. The DON acknowledged the absence of documentation showing that the resident's meal preferences were offered, which could lead to meal refusals and potential weight loss. The facility's policy on accommodating resident needs and food preferences was not adhered to, as evidenced by the lack of Mexican food options provided to Resident 68.
Failure to Offer Pneumococcal Vaccine Upon Readmission
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to Resident 2 upon readmission on 9/26/2024, as required by the facility's policy. Resident 2, who was admitted with conditions including ventricular tachycardia, Parkinson's Disease, and major depressive disorder, had previously refused the vaccine on 4/14/2022. However, there was no documentation of the vaccine being offered or declined during the current admission, nor was there any record of education provided to the resident about the vaccine. Interviews with the Director of Nursing and the Infection Preventionist Nurse confirmed that the facility's protocol requires staff to offer the pneumococcal vaccine during all admissions and readmissions, and to document the administration or declination in the resident's medical record. The Infection Preventionist Nurse acknowledged that the vaccine was not offered to Resident 2 during the current admission, which was a deviation from the facility's policy. Resident 2 expressed interest in receiving the vaccine, citing a history of pneumonia, but could not recall being offered the vaccine during the current admission.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required square footage per resident bed in 25 out of 27 resident rooms. The deficiency was identified during a re-certification survey conducted from October 15 to October 18, 2024. Observations revealed that rooms 1 to 9 and 11 to 26 did not meet the minimum requirement of 80 square feet per resident. Despite the deficiency, residents did not express complaints about the room size, and staff reported that there was sufficient space to provide care and store residents' belongings. Wheelchair-bound residents were able to move in and out of their rooms without difficulty. Interviews with residents and staff further supported that the room sizes did not hinder the provision of care. For instance, Resident 45, who uses a wheelchair, stated that she had no issues with the room size and that staff assistance was adequate. Similarly, a Certified Nursing Assistant (CNA) reported that the room was spacious enough to care for residents, as demonstrated by the successful transfer of Resident 52 from bed to wheelchair. Despite these observations, the facility's room waiver request indicated that the rooms did not meet the required square footage, prompting the Department to recommend a waiver for the affected rooms.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brighton Care Center | 0 mi | ★★★★★ | 25 | 0 |
| Golden Rose Care Center | 0.1 mi | ★★★★★ | 9 | 0 |
| Camellia Gardens Care Center | 0.1 mi | ★★★★★ | 18 | 0 |
| Cedar Pine Post Acute | 0.2 mi | ★★★★★ | 11 | 0 |
| Pasadena Nursing Center | 0.3 mi | ★★★★★ | 27 | 0 |
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