Federal inspectors discovered the contaminated food during a July inspection of the facility's kitchen, which serves meals to 43 residents.
Nursing Home News — Page 285
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The incident occurred on January 14, 2025, when the resident became "increasingly agitated" because she wanted her medication schedule changed from 9 p.m.
The resident, who had been admitted with a history of brain hemorrhage, scored a perfect 15 out of 15 on his cognitive assessment in May.
Administrative staff confirmed they expected nurses to follow these basic safety protocols.
Resident 53 had been readmitted to Dreier's Nursing Care Center in May after a fall at the facility led to hospitalization for altered mental status.
Each time he removed dirty gloves and put on clean ones, he skipped the required hand hygiene step.
The 87-year-old with severe Alzheimer's disease left the facility at 1:35 PM on June 14 after nurses discovered the medical emergency at 1:05 PM.
The violation at St Vincent's - A Prospera Community illustrates how basic infection control failures can put vulnerable residents at risk.
Federal inspectors determined the pattern created immediate jeopardy to resident safety.
The resident had acute respiratory failure, a tracheostomy, and was at high risk for falls.
The resident's family member called the facility in June 2024, concerned about developing contractures in hands and legs.
Seven days later, the same two residents argued again on the patio about personal space.