Villa St. Vincent

Inspectors wroteBased on observation, interview, and document review, the facility failed to protect residents' rights to be free from sexual abuse by failing to complete a comprehensive assessment for capacity to consent to sexual activity for 2 of 2 residents (R58, R61) with cognitive impairment who engaged in sexual activity. In addition, the facility failed to investigate unexplained bruising and vaginal bleeding for 1 of 1 resident (R58) in the context of known sexual activity. These failures resulted in an Immediate Jeopardy (IJ) as the facility did not determine whether either resident possessed the capacity to knowingly and voluntarily consent to sexual activity, creating a likelihood that one or both residents were subjected to non-consensual sexual contact and placing them at risk for serious harm, impairment, or injury. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to honor a resident's right to make choices regarding daily activities by implementing a blanket requirement that residents be accompanied by staff when accessing a secured outdoor courtyard, without an individualized assessment of the resident's safety, abilities, or need for supervision. This affected 1 of 2 residents reviewed for resident rights (R42), who expressed a desire to independently access the courtyard as part of his customary routine.

Inspectors wroteBased on interview and document review, the facility failed to support a resident's expressed choice regarding smoking for 1 of 1 resident (R17) reviewed for resident choices. The facility failed to assess R17's request to smoke, evaluate options to accommodate the preference, and involve the interdisciplinary team after R17 repeatedly expressed a desire to resume smoking.

Inspectors wroteBased on observation, interview and document review, the facility failed to monitor and reevaluate the continued need for a wander guard utilized as a means to restrict the resident from accessing the outdoors for 1 of 1 resident (R17) reviewed for restraints. The facility failed to complete a reassessment despite changes in R17's behaviors and expressed desire to independently access the outdoors, resulting in the continued use of the intervention without documentation supporting ongoing need.

Inspectors wroteBased on interview and document review, the facility failed to report allegations and suspicions of resident-to-resident sexual abuse to the State Agency for 2 of 2 residents (R58 and R61) reviewed for abuse after becoming aware that the residents, who had significant cognitive impairment, were engaging in sexual activity without a determination of their capacity to consent. The facility also failed to report potential injuries of unknown source for 1 of 2 residents (R58) who exhibited unexplained bruising and vaginal bleeding.

Inspectors wroteBased on interview and document review, the facility failed to investigate potential resident-to-resident sexual abuse for 2 of 2 residents (R58, R61) reviewed for abuse. The facility became aware of repeated sexual activity between two residents with significant cognitive impairment but failed to assess either resident's capacity to consent to sexual activity. As a result, the facility was unable to determine whether the encounters were consensual and failed to complete a thorough abuse investigation. Additionally, the facility failed to investigate bruising and reports of vaginal bleeding experienced by R58 in relation to the known sexual activity.

Inspectors wroteBased on interview and document review, the facility failed to provide education regarding the benefits and potential side effects of pneumococcal vaccination and failed to document that education was provided prior to obtaining a vaccination decision from the resident representative for 1 of 5 residents (R42) reviewed for immunizations.

Inspectors wroteBased on interview and document review, the facility failed to ensure eligible residents received COVID-19 vaccination after consent was obtained for 1 of 5 residents (R30); and the facility failed to provide current Centers for Disease Control and Prevention (CDC) COVID-19 vaccine education regarding the potential benefits and risks of vaccination to resident representatives prior to obtaining a refusal for 2 of 5 residents (R16, R42) reviewed for COVID-19 vaccination status. These failures resulted in one resident not receiving a consented-to vaccination and had the potential to affect residents' ability to make informed vaccination decisions.

Inspectors wroteBased on interview and document review the facility failed to ensure residents remained free from significant medication errors. This resulted in actual harm to R1 who was administered opioid medications prior to the prescribed date resulting in hypoxia, confusion and unresponsiveness and required the use of Narcan (used to reverse the effects of an opioid overdose).

Inspectors wroteBased on observation, interview and document review the facility failed to protect the residents right to be free from physical abuse by other residents for 2 of 3 residents (R2, R3) when care plan intervention to adequately increase supervision to protect residents from abuse were not implemented and behaviors were not investigated or documented with detail to assist in determining possible antecedents of the negative behavior. Additionally, the facility failed to monitor R3 for mood and behavioral changes following a resident-to-resident abuse incident which resulted in minor injuries and increased withdrawal. R2's Resident Face Sheet indicated she admitted to the facility 10/19/23. R2's diagnosis included Alzheimer's disease, insomnia and dementia with behavioral disturbance. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure timely reporting to the state agency (SA) of a significant medication error for 1 of 3 residents (R1) reviewed for medication errors and failed to ensure timely reporting of an incident of resident to resident abuse for 2 of 3 residents (R2,R3) reviewed for abuse.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure care planned interventions to reduce the risk for falls were followed for 2 of 4 residents (R1, R3). This resulted in actual harm for R1 who fell and sustained a vertebral fracture.

Inspectors wroteBased on observation, interview and document review, the facility failed ensure their infection control surveillance contained all data to effectively track, trend, analyze infections with the potential to affect all residents residing in the facility; and the facility failed to ensure enhanced barrier precautions and standard precautions for 1 of 2 residents (R140) reviewed for wound care; and failed to ensure contact precautions were followed for 1 of 3 residents (R75) reviewed for transmission-based precautions.

Inspectors wroteBased on interview and document review, the facility failed to follow through on a grievance regarding missing clothing for 1 of 1 resident (R9) reviewed for grievances.

Inspectors wroteBased on interview and document review, the facility failed to ensure use of an as-needed (PRN) psychotropic medication was limited to a 14-day period and/or obtain justification for continued use by the provide for 1 of 5 residents (R68) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview and document review the facility failed to implement interventions to protect 2 of 2 residents (R1, R2) from resident to resident abuse when R2, who had a history of pushing other residents, initiated an altercation with R1 which resulted in R1's transport to the Emergency Department (ED) for a scalp laceration repaired with sutures. This resulted in harm for R1.

Inspectors wroteBased on interview and document review, the facility failed to ensure a gait belt was used when transferring/walking 1 of 5 residents (R296) reviewed for falls. This resulted in actual harm for R296 who fell while being transferring and received a lumbar fracture. The facility implemented corrective action prior to the investigation so the deficient practice was issued at past non-compliance.

Inspectors wroteBased on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 4 of 5 residents (R3, R13, R70, R72) reviewed for immunizations.

Inspectors wroteBased on interview and document review, the facility failed to ensure a significant change in status Minimum Data Set (MDS) was completed as directed for 2 of 2 residents (R64, R296) reviewed for significant change in status.

Inspectors wroteBased on interview and document review, the facility failed to ensure the provider documented a thorough rationale for continued use of medications for 1 of 5 residents (R64) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure there was a process to ensure a gradual dose reduction (GDR) or adequate medical justification documented for psychotopic medications was implemented for for 1 of 5 residents (R64) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure medications were safely and securely stored for 1 of 1 resident (R70) reviewed for medication storage.

Inspectors wroteBased on interview and document review, the facility failed to provide timely INR (a standardized measurement of how long it takes the blood to clot) level results for a resident on warfarin sodium (a blood thinning medication) for 1 of 2 resident (R52) reviewed who were taking warfarin.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure enhanced barrier precautions (EBP) were utilized with residents with a catheter for 2 of 2 residents (R1, R69) reviewed for catheters.

Inspectors wroteBased on observation, interview and document review the facility failed to develop and implement interventions to ensure adequate supervision for 1 of 1 residents (R5) reviewed who had multiple incidents of unsafe behavior related to marijuana use.