St. Dominic Village Rehabilitation and Nursing Cent

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services a complete and accurate direct care staffing information, including information for agency and contract staff, based on 1 of 4 quarters for payroll and other verifiable and auditable data in a uniform format according to specification established by Centers for Medicare and Medicaid Services. The facility failed to submit to Centers for Medicare and Medicaid Services the Payroll Base Journal data for the second quarter of 2026. The failure could put Residents at risk for inadequate staffing and not having their needs meets.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 13% based on 4 errors out of 30 opportunities, which involved 3 of 4 residents (Resident #1, Resident #51, and Resident #75) and 1 of 1 staff (MA A) observed during medication administration reviewed for medication errors. The facility failed to ensure:1. Resident #1's Aspercreme lidocaine patch 4% was applied to the correct area of the body as ordered2. Resident #1 received the enteric coated extended release aspirin instead of chewable aspirin3. Resident #51 did not receive Vitamin D 25 mcg without a physician's order4. Resident #75 received the correct dosage of Cetirizine HCl Theses failures could place residents at risk of not receiving therapeutic dosages and/or effects of medications.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #9) reviewed for adequate supervision. The facility failed to ensure Resident #9 had quarterly fall risk assessments completed. The failure could place residents at risk of possible injury and not having appropriate interventions in place.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 2 of 5 residents reviewed for immunizations. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 2 of 5 residents who were reviewed for immunizations. (Resident #3 and Resident #65) The facility failed to document, in Resident #3's and Resident #65's medical records, having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free from misappropriation (Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.) for 1 of 5 residents (Resident #1) reviewed for misappropriation. The facility failed to protect Resident #1 from being exploited when LVN A deliberately used $800 from the resident's money without the resident's consent. This failure may cause residents to be left without sufficient funds to pay for their own care necessities, psychological distress, paranoia, and feelings of guilt and shame that could prevent them from reporting abuse, neglect, or exploitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 out of 5 residents (Resident #2, Resident #3, Resident #4, and Resident #5), reviewed for care plans. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents were free from sexual abuse and physical abuse for three of ten residents (Resident #61, #52 and #48) reviewed for abuse.-The facility failed to have a policy and procedure in place to address the determination of capacity to consent to sexual activity for residents who lacked the cognitive ability to consent. On 2/25/25 RA A witnessed inappropriate sexual behavior between two residents who had dementia. Resident #61 had his mouth on Resident #52's breast.-The facility failed to ensure Resident #48 was free of abuse when CNA A pushed Resident #48's face into his bed railings while providing incontinence care. This deficient practice could place residents at risk of non-consensual sexual relations, physical pain, psychosocial distress and feeling uncomfortable.

Inspectors wroteBased on observation, interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 7 Residents (Resident #61, Resident #52 and Resident #17) reviewed for care plans. The facility failed to ensure Resident #61's care plan with interventions for the inappropriate sexual interaction on 2/25/2025 was documented in a timely manner. The facility failed to ensure Resident #52's care plan with interventions for the inappropriate sexual interaction on 2/25/2025 was documented in a timely manner. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 1 medication carts (Unit 2-B Nursing Cart) reviewed for medication storage . The facility failed to ensure Unit 2-B Nursing cart revealed was not unlocked and unattended with medication on top of the cart. This failure could place residents at risk of adverse reactions to medications and misappropriation of medications.

Inspectors wroteBased on interview, and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASARR) program to the maximum extent practicable for 1 of 5 residents (Resident #17) reviewed for PASARR. The facility failed to update the PASARR Level 1 forms for Resident #17 to indicate mental health illness. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight for 1 of 5 residents (Residents #31) reviewed for nutrition. - The facility failed to ensure the implementation of the Registered Dietitian's recommendations that included Fortified meals for Resident #31. This failure could place residents at risk for weight loss and decline in health status.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs for 1 of 4 medication Carts (Station 1 PRN Nursing Cart) reviewed for pharmaceutical services. - The facility failed to ensure the Station 1 PRN nursing cart did not contain an expired bottle of Vitamin C 250 mg. This failure could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled health conditions. Findings Included: In an observation on 02/08/24 at 07:10 AM, inventory of the Station 1 PRN Nursing Cart with LVN A revealed: - An expired, open and in use stock bottle of Vitamin C 250 mg with a manufacturer's expiration date of 01/2024. [...]

Inspectors wroteBased upon observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and under proper temperature controls for 1 out of 8 Residents (Resident #43) and 1 of 4 medication carts ( Station 3 Medication Cart) reviewed for drug labeling and storage. - The facility failed to ensure the Station 3 Medication Cart did not contain an in-use insulin pen for Resident #43 with no open date. This failure could place residents at risk of adverse medication reactions and drug diversions.