Vancrest of St Mary's

In the surveyor’s words

From the most serious findings on record at Vancrest of St Mary's, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Dec 18, 2025

  Based on medical record review, resident interview, staff interview and review of facility policy, the facility failed to implement appropriate infection control practices during care of residents on isolation. This affected Resident #2. Additionally, the facility failed to ensure proper signage was posted for type of isolation and usage of personal protective equipment (PPE) for residents who were on isolation. This affected four Residents (#59, #4, #1, #44, and #23). Six residents were reviewed for isolation practices. The facility census was 45.Based on medical record review, resident and staff interview, and policy review, the facility failed to implement appropriate infection control practices during care of residents on isolation. […]

• No harm, potential for more than minimal, patternF880Nov 22, 2023

  Based on observation, staff interview, and review of policy, the facility failed to maintain hand hygiene while delivering meal trays on the 200 hall. This had the potential to affect 12 (#24, #35, #37, #95, #96, #97, #98, #99, #100, #101, #102, and #103) of 12 residents residing in the 200 hall. The facility census was 47. Findings include: Observation, on 11/20/23 beginning at 11:20 A.M., during the lunchroom tray delivery on the 200 hall, revealed the Director of Nursing (DON) was observed to enter the room of Resident #98 and touch the resident's glasses and cell phone. DON placed the tray onto the over bed table and proceeded out of the room and began reaching for another resident tray. […]

• No harm, potential for more than minimal, isolatedF656Dec 18, 2025

  Based on record review, staff interview and policy review, the facility failed to ensure residents had accurate comprehensive, person centered and individualized care plans that reflected the residents' current orders, diagnoses and treatment decisions. This affected two (#5, #23) of two residents reviewed for care planning. The facility census was 45.Based on medical record review, staff interview and policy review, the facility failed to ensure residents had accurate comprehensive, person centered and individualized care plans. This affected two (#5 and #23) of two residents reviewed for care planning. The facility census was 45. Findings include: 1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, isolatedF635Nov 22, 2023

  Based on medical record review, hospital paperwork review, staff interview, and resident interview, the facility failed to obtain admission physician orders for the treatment of a surgical wound present on admission. This affected one (#97) of one residents reviewed for admission. The facility census was 47. Findings include: Review of the medical record of Resident #97 revealed an admitted [DATE]. Diagnoses include non-ST elevation myocardial infarction, atherosclerosis of autologous artery coronary artery bypass graft with angina pectoris with documented spasm and combined systolic (congestive) and diastolic (congestive) heart failure. Review of the hospital discharge paperwork dated 11/15/23 revealed Resident #97 was status post left heart catheterization. […]

• No harm, potential for more than minimal, isolatedF641Nov 22, 2023

  Based on record review and staff interview, the facility failed to accurately assess residents' medications for quarterly Minimum Data Set (MDS) assessments. This affected two (#23 and #36) of 16 residents reviewed for accurate assessments. The current census is 47. Findings include: 1. Record review for Resident #23 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #23 included: fracture of femur, aftercare post-surgery, muscle weakness, chronic obstructive pulmonary disease, and anxiety. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. […]