The January incident at Providence Mount St Vincent illustrates broader medication safety failures found throughout the 505-bed facility during a federal inspection. Inspectors discovered expired medications and medical supplies scattered across four medication rooms and one medication cart, with some items expired for over a year.
In the 4 South medication room, inspectors found an immunization vaccine that expired December 18, 2023, sitting alongside three bottles of ostomy care powder that expired in October 2024. The licensed practical nurse on duty acknowledged the expired items "should not have been in the medication room as it could cause harm to a resident and would not be as effective."
The 5 North medication room contained the most extensive collection of expired supplies. Four urinary catheter kits had expired in September 2024. A specimen collection kit bore an expiration date of January 31, 2021. Three wound dressings expired October 31, 2023. An injectable medication expired December 30, 2024, just 11 days before inspectors arrived.
Two bottles of cleaning solution chemicals had expiration dates so worn off they were illegible.
Staff acknowledged the violations but offered little explanation. "They should check the medication cart periodically but missed the opportunity to remove the expired medication," one nurse told inspectors about a November 2024 over-the-counter medication found on the 5 South cart.
The Director of Nursing told inspectors that nurses "should check the med carts and med rooms and dispose of the expired medications," but acknowledged this wasn't happening. A manager stated that "all nurses were responsible for checking medication storage for expired medication, this did not happen but should have."
The unsecured inhaler incident on January 2 revealed additional safety gaps. Resident 89, assessed with severely impaired memory and chronic respiratory disease, was left alone with the medication device in the facility's 300 South dining room. Another resident pointed to the inhaler and identified it as belonging to Resident 89.
Staff QQ, the licensed practical nurse responsible, returned from break 30 minutes later to find the inhaler still on the table. She admitted to inspectors that she "did not know if Resident 89 had intact memory or was assessed to able to administer their own medications prior to giving it to them." She said she "should have but did not verify" the resident's ability to self-administer before leaving the medication unsupervised.
It was Staff QQ's first day working that unit.
Food safety violations compounded the medication problems. In the main kitchen, inspectors observed a cook answer the phone with gloved hands, then put on new gloves without washing hands and return to frying shrimp. Another cook touched their surgical mask, then handled chicken, freezer handles, fryer baskets, and shrimp packages before finally washing hands three minutes later.
Kitchen equipment sat contaminated for extended periods. The meat slicer was uncovered, allowing dust and contaminants to accumulate on its surfaces. A stand mixer bowl sat right-side up on a shelf with nothing preventing contamination inside. Two food processor bases showed "substantial amounts of dried-up food splatter of different colors and consistencies." The can opener blade had "dried buildup of food."
On the 4th floor North unit, a nutrition attendant wore a hairnet covering only the top half of her hair while checking food temperatures. She used the same thermometer probe on shrimp, carrots, mashed potatoes, gravy, and multiple other dishes, wiping it only with paper towels instead of sanitizing with alcohol swabs between different foods.
When a supervisor approached and provided sanitizer wipes, the attendant used one once, then returned to checking temperatures with paper towels.
Certified nursing assistants serving food violated basic hygiene protocols repeatedly. On 4th floor South, one CNA delivered food trays to resident rooms, including a room requiring enhanced barrier precautions, without washing hands between deliveries. The CNA moved a housekeeping cart with bare hands, delivered a tray, and returned to pour coffee for another resident without hand washing.
Another CNA served lunch with the same gloves after touching a table, then entered a room requiring protective equipment without donning required gowns and gloves.
Staff violated infection control protocols designed to protect vulnerable residents. Three residents requiring enhanced barrier precautions received care from staff who failed to wear required gowns. One nurse administered liquid nutrition through a feeding tube to a resident with severely impaired vision, but when the tubing fell on the floor, she picked it up and reattached it to the patient instead of getting clean tubing.
"I was nervous and forgot to grab new tubing," the nurse told inspectors.
The facility's infection preventionist explained that enhanced barrier precautions protect "fragile residents with indwelling medical devices or wounds from contracting an infection." Yet staff repeatedly ignored the posted signs requiring protective equipment.
Patient privacy violations added to the facility's problems. On the 5 North unit, inspectors found a resident's interdisciplinary team progress note in a grievance file folder accessible to anyone near the elevator. A resident roster containing sensitive information lay uncovered on top of a medication cart where anyone could see it.
The licensed practical nurse responsible for the exposed roster admitted she "should have covered the sensitive resident information on the report sheet before walking away from their cart but forgot."
Hospice care coordination failures affected at least one terminally ill resident. Resident 170, diagnosed with cancer and admitted to hospice services in December, had no physician's order for hospice care in their record. The resident's care plan provided minimal guidance to staff, and hospice visit notes weren't uploaded to the facility's records until weeks after the visits occurred.
The facility's own collaboration form with hospice providers was largely blank, with intervention sections left empty and no documentation of when the next hospice visit would occur or who received communications about the resident's care.
A nursing manager reviewed Resident 170's records and told inspectors they were "unfortunately lacking." The administrator acknowledged expectations weren't met for coordinating hospice services, including ensuring orders, care plans, and progress notes were readily available.
The Director of Nursing summed up the facility's failures simply: staff were expected to follow infection control policies and maintain medication safety, "but they did not."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Providence Mount St Vincent from 2025-01-10 including all violations, facility responses, and corrective action plans.