Providence Mount St Vincent

In the surveyor’s words

From the most serious findings on record at Providence Mount St Vincent, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 10, 2025

  Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 8 of 12 residents (Residents 1, 2, 3, 4, 5, 6, 7, & 8) reviewed for abuse. Resident 1 experienced physical harm when Staff D (Certified Nursing Assistant - CNA) grabbed the resident's arms which left fingerprint bruises and a nail inflicted skin tear;after the incident as demonstrated by mood changes including frequent crying, increased behaviors of distress, multiple days of refused care and medications, and repetitive verbalized statements of fear of being physically hurt. These failures placed residents at risk of verbal, physical, mental, psychological abuse, and diminished quality of life. […]

• Actual harm, isolatedF626Feb 7, 2025

  Based on interview and record review, the facility failed to permit 1 of 3 residents (Resident 1) reviewed for hospitalization to return to the facility after a facility-initiated transfer to the emergency room (ER). Resident 1 experienced psychological harm when they experienced a two-week long hospitalization delay while another nursing facility could be arranged for discharge, anxiety related to being placed in an unfamiliar environment, expressions of fear of homelessness and hopelessness when the facility failed to permit the Resident 1 to return to the facility and resume residency when they were medically cleared by the hospital to discharge. […]

• Actual harm, isolatedF600Jan 10, 2025

  Based on interview and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 5 sample residents (Residents 110) reviewed for abuse. Resident 110 experienced psychological harm when they were touched inappropriately without consent by a staff member and continued to ruminate on the incident. This failure placed other residents at risk of sexual, verbal, and mental abuse, psychological harm, and diminished quality of life. Findings included . <Facility Policy> The facility's Abuse Prohibition and Prevention policy dated 01/2024, all residents receiving care and services at the facility had the right to be free from mistreatment including sexual, physical, mental, and verbal abuse. […]

• Actual harm, isolatedF689May 14, 2024

  Based on observation, interview, and record review the facility failed to ensure an environment free of avoidable accidents/injuries for 1 of 7 residents (Resident 1) reviewed for accidents. The failure to ensure nursing staff followed the resident care plan (CP) and facility policy while transferring Resident 1 using a mechanical lift resulted in harm when the resident was transferred by one staff person instead of two staff persons, obtained a laceration on the right leg, and was hospitalized for five days. This failure placed residents requiring a mechanical lift transfer at risk for injury, hospitalization , and diminished quality of life. […]

• Actual harm, isolatedF689Mar 17, 2022

  Based on observation, interview, and record review the facility failed to provide supervision for 1 of 6 (Resident 1) residents reviewed for wandering and elopement and failed to ensure all exits were secured. These failures allowed Resident 1 to exit the facility, onto a parking lot adjacent to the facility, resulting in a fall with a significant head injury, that required continued hospitalization and placed all residents who wandered at risk for elopement and suffering significant injury. Findings included . Review of a 03/04/2022 Admission note showed Resident 1 had a black Global Positioning Device (GPS) on the left wrist, memory impairment, behaviors, and due to dementia required closer supervision to prevent falls. […]