Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villa St Vincent during CMS and state inspections, most recent first.
A facility failed to protect two residents with severe cognitive impairment from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent after repeated sexual encounters were discovered. Staff found the residents together in bed or in the bathroom, often unclothed, and allowed privacy based on their behavior without documenting a structured consent assessment. The facility also did not fully investigate unexplained bruising and reported vaginal bleeding for one resident in the setting of the known relationship, and the MD was not notified of the incidents or injuries.
A resident with intact cognition, wheelchair mobility, and a care plan noting a preference for independent activities and going outside was not allowed to access a secured courtyard on his own because the facility applied a blanket supervision rule. He said he had previously gone out whenever he wanted, but staff now required escort due to another resident's fall, and staff told him the rule applied to everyone. Interviews confirmed no individualized assessment had been done to determine whether residents could safely access the courtyard independently, and the courtyard door and gate were locked with no call system available.
A resident with moderate cognition and a history of smoking repeatedly expressed a desire to smoke, but staff told her she could not because the campus was smoke-free. Her care plan did not address smoking, no updated smoking assessment was completed after she voiced her preference, and the IDT did not document discussion of options to accommodate off-campus smoking despite the facility policy calling for individualized assessment and consideration of safe smoking practices.
A resident with dementia, anxiety, depression, and diabetes was kept on a wander guard that restricted access to the outdoors, but the facility did not document the required reassessment of continued need. The resident stated she disliked wearing the device and wanted it removed because it prevented her from enjoying the outdoors, while staff and the DON acknowledged the device should have been reviewed quarterly and could not find documentation of a reassessment.
Failure to Report Suspected Abuse and Unexplained Injury Staff found two cognitively impaired residents repeatedly in bed together without clothing, but the incidents were only documented in progress notes and not reported to the SA because the team believed the interactions were consensual. One resident also had unexplained bruising and reported bloody discharge, yet the bruises and possible injury of unknown source were not reported as required. Neither resident had a documented capacity-to-consent assessment, and both care plans called for monitoring of their interactions and reporting suspected abuse.
Failure to Investigate Possible Resident-to-Resident Sexual Abuse: Two residents with severe cognitive impairment were repeatedly found unclothed together, but the facility did not assess either resident’s capacity to consent or complete a formal abuse investigation. The record also showed bruising and a report of bloody vaginal discharge for one resident, and staff, including the DON, stated no assessments or investigations were completed and the encounters were assumed to be consensual based on the residents’ behavior.
Failure to Document Pneumococcal Vaccine Education Before Consent: A resident with mild cognitive impairment and multiple chronic conditions had a pneumococcal vaccine decision declined by the son, but the record did not show that the resident or representative received education on the benefits, side effects, or booster guidance before the refusal was obtained. RN-B stated the family declined by phone and no education was mailed or documented, while the DON stated residents and representatives need full vaccination education and documentation of their understanding.
COVID-19 Vaccination Consent and Education Deficiencies: The facility failed to administer a COVID-19 vaccine to a resident who had already consented, and failed to document CDC vaccine education for two residents whose sons declined vaccination by phone. The RN responsible for infection prevention stated the facility did not currently have COVID-19 vaccine available and did not mail or document education for family review, while the DON stated residents and resident representatives needed full vaccination education and documentation of understanding.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety but does not provide further details about the specific events or individuals involved.
The facility did not promptly report a significant medication error involving a resident who received both oxycodone and morphine, leading to hospitalization for opioid overdose, nor did it report a resident-to-resident abuse incident within the required timeframe. In both cases, the DON delayed notification to the state agency, contrary to facility policy requiring immediate reporting of such events.
Two residents at high risk for falls did not receive care planned interventions, including use of transfer belts, slip grips, and appropriate staff assistance during transfers and ambulation. As a result, one resident suffered a vertebral fracture after a fall, and another experienced multiple falls, some unwitnessed, due to staff not following or being aware of the required interventions.
The facility failed to maintain complete infection surveillance data and did not ensure proper use of enhanced barrier and contact precautions for residents with infections and wounds. Staff did not consistently use required PPE or perform hand hygiene during wound care, and housekeeping staff did not follow contact precaution protocols while cleaning a room of a resident with norovirus. Care plans did not always reflect the need for specific precautions, and staff demonstrated inconsistent understanding of infection control requirements.
A resident with severe cognitive impairment and dementia had a significant amount of clothing and slippers go missing after being brought to the nurses' desk, as reported by a family member. Although staff made some attempts to locate the items, there was no formal documentation of the grievance or follow-up, and the family was not reimbursed. The facility did not follow its grievance policy or ensure proper reporting and resolution of the issue.
A facility failed to protect two residents from abuse, resulting in one resident being harmed. Despite R2's history of aggression and R1's tendency to wander, staff lacked specific supervision plans. R2 pushed a chair R1 was holding, causing her to fall and sustain a head injury. The facility's interventions were insufficient to prevent the incident.
A resident with moderate cognitive impairment and at risk for falls was not assisted with a gait belt during a transfer, contrary to their care plan. The resident fell in the bathroom, resulting in a lumbar compression fracture. The incident led to significant pain and deterioration in the resident's condition, eventually resulting in hospice care and the resident's passing. Staff interviews confirmed the expectation of gait belt use during transfers, which was not followed in this case.
The facility failed to offer updated pneumococcal vaccinations (PCV15 or PCV20) to four residents, despite CDC recommendations. The residents, who had various medical conditions, had received previous pneumococcal vaccines, but their records lacked evidence of the newer vaccines being offered. The RN responsible for infection prevention was aware of the need but had not yet offered the vaccines, and the DON was unaware of the oversight. The facility's policy had not been updated to reflect new CDC guidelines.
A facility failed to ensure a provider documented a rationale for continued use of antidepressants for a resident. Despite a pharmacist's recommendation for a trial reduction, the primary physician continued the medication without proper documentation. The DON acknowledged issues with providers not addressing pharmacy recommendations, and the Medical Director planned to address the problem.
A facility failed to ensure a process for gradual dose reduction (GDR) or adequate medical justification for a resident's continued use of psychotropic medications. Despite a consultant pharmacist's recommendation for a trial reduction, the primary physician did not provide further documentation or justification. Interviews revealed a lack of awareness and follow-up on the pharmacist's recommendations, and no clear nursing process was identified to address GDRs.
A resident with moderate cognition and multiple health issues had medications left unsecured in their room. The facility's records showed an order for a wound cleanser but not for Nystatin powder, which was also found in the room. Nursing staff acknowledged the medications should not be left unsecured, and the facility's policy requires secure storage.
A resident on warfarin sodium did not receive timely INR results, leading to potential health risks. The facility failed to promptly communicate INR results to the medical provider, with delays in documentation and response. Staff interviews revealed inconsistencies in handling INR results, and the facility's policy lacked clear guidelines for timely reporting and follow-up actions.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with indwelling catheters, leading to a deficiency in infection prevention and control. Observations showed no PPE carts or gowns used during care, and staff interviews revealed a lack of clarity on EBP implementation. The facility's policy required EBP for residents with indwelling devices, but it was not applied to these residents.
The facility failed to complete significant change MDS assessments for two residents who experienced declines in mobility and care needs. One resident became dependent on staff for transfers and unable to ambulate, while another was admitted to hospice care following a fall. The responsible RN and LPN did not recognize or schedule the necessary assessments, leading to deficiencies in care planning.
The facility failed to adequately supervise a resident with schizo-affective disorder and dementia who had multiple incidents of unsafe behavior related to marijuana use. Despite having a care plan and a marijuana use contract, the resident was frequently observed using marijuana unsupervised, leading to multiple falls and unsafe behaviors. Staff interviews revealed a lack of clear communication and understanding of the resident's fall interventions and marijuana use contract, contributing to the resident's repeated falls and unsafe behaviors.
Failure to Assess Consent and Investigate Injury With Resident Sexual Activity
Penalty
Summary
The facility failed to protect two cognitively impaired residents from sexual abuse by not completing a comprehensive assessment of each resident’s capacity to consent to sexual activity after becoming aware that they were engaging in sexual contact. One resident had diagnoses including Alzheimer’s disease, neurocognitive disorder with Lewy bodies, dementia, and anxiety, with documentation showing severe cognitive impairment, wandering, hallucinations, confusion, and inability to consistently orient to time or place. The other resident also had diagnoses including Alzheimer’s disease and dementia with psychotic disturbance, with repeated BIMS scores showing severe cognitive impairment and care plan documentation noting cognitive loss and a history of wandering and checking doors. The record showed repeated incidents in which the two residents were found together in bed or in the bathroom, often unclothed, and staff documented that they appeared calm or did not show obvious distress. Staff notes and interviews showed that the residents were allowed privacy and continued access to each other without documentation of a formal assessment of whether either resident understood the nature of the relationship or could knowingly and voluntarily consent. Staff interviews also reflected that they relied on the residents’ behavior, such as whether they pushed away or said no, rather than documenting a structured assessment of capacity after each incident. The facility also failed to investigate unexplained bruising and reported vaginal bleeding for one resident in the context of the known sexual activity. The record documented bruises on the forearms and thigh in various stages of healing, along with a report of bloody vaginal discharge, but there was no evidence of a physical assessment or investigation to determine whether the findings were related to abuse, coercion, trauma, or another cause. Interviews with the RN, LPN, DON, MD, and family showed that the physician had not been notified of the sexual incidents, the bruising, or the vaginal bleeding, and that staff had not documented a formal assessment after the incidents.
Blanket Supervision Rule Restricted Resident Access to Courtyard
Penalty
Summary
The facility failed to honor a resident's right to make choices regarding daily activities by applying a blanket rule that residents had to be accompanied by staff to access a secured outdoor courtyard, without an individualized assessment of the resident's safety, abilities, or need for supervision. This affected one of two residents reviewed for resident rights, a resident with intact cognition who was independent with most ADLs and transfers, used a wheelchair for mobility, and had diagnoses including paranoid schizophrenia, dementia, CHF, above-the-knee amputation, delusional disorders, generalized anxiety, and PTSD. His care plan identified that he was pleasant, able to make his needs known, preferred independent activities, and enjoyed going outside. The resident stated he had previously been able to go to the locked unit's fenced courtyard whenever he wanted, but staff told him he could no longer go unless accompanied by staff because another resident had fallen there. He reported that he preferred going outside in the morning when it was cooler and less windy, but staff were not available then and instead took him out later in the day when it was hotter. He also stated he had complained to the unit nurse, activities, social worker, and administration, but was told it was the rule for the unit. Survey observations showed the resident in the courtyard with another resident and an unidentified staff member nearby, and later the staff member told the residents they had to return inside. Interviews with RN, SW, DON, and the administrator confirmed that residents were being kept from going to the courtyard unsupervised, that no resident had been individually assessed for safe independent access, and that the facility had implemented the supervision practice after a recent fall. Staff also stated the courtyard gate and building access were locked, there was no call system for residents outside, and the facility had not evaluated each resident to determine whether they could safely access the courtyard independently.
Failure to Support Resident Smoking Preference
Penalty
Summary
The facility failed to support a resident’s expressed choice regarding smoking for 1 resident who had moderate cognition and was able to make her needs known. The resident’s diagnoses included dementia, anxiety, depression, and diabetes. Her smoking risk assessment noted a history of smoking but stated she did not plan to smoke during her stay, and her care plan did not address a smoking preference. However, progress notes documented that she told the LSW on two occasions that she wanted to go outside and have a cigarette and that she missed smoking and wished she could still smoke. The facility did not document an assessment of the resident’s ability to smoke safely off campus after she expressed interest in smoking, and the care conference note did not identify any discussion of her desire to smoke. During a resident council meeting, the resident stated she wanted to smoke but was told by staff that she could not. The LSW stated the resident requested smoking on two occasions, but follow-up discussions with the IDT were not documented and the IDT did not evaluate options to accommodate her preference. The RN stated residents with a smoking history were assessed on admission, but no smoking assessment had been completed since admission for this resident. The facility maintained a blanket practice prohibiting smoking by new residents, while its policy stated residents who wished to smoke were to be assessed for safe smoking practices and ability to smoke independently off campus.
Failure to Reassess Continued Need for Wander Guard
Penalty
Summary
The facility failed to monitor and reevaluate the continued need for a wander guard used to restrict a resident from accessing the outdoors for 1 of 1 resident reviewed for restraints. The resident had moderate cognition, was independent with activities of daily living, and had diagnoses including dementia, anxiety, depression, and diabetes. The resident’s quarterly MDS identified daily use of a wander/elopement alarm, and the restraint/adaptive equipment assessment noted use of antidepressants, antipsychotics, anxiolytics, and narcotics, along with a recent decline in condition, but did not specify the decline. The assessment also indicated no alternatives had been attempted before initiating the wander guard and that it was to be used at all times, while the questions about whether the device met the definition of a physical restraint were left unanswered. During observation, the resident was wearing the wander guard bracelet and stated staff had placed it on her wrist when she arrived at the facility. The resident stated she was able to go outside, but the alarm sounded when she walked through the doors and staff came to check on her. She stated she did not like wearing the device and wanted it removed because it prevented her from enjoying the outdoors. Nursing staff and social work staff stated wander guard assessments were to be completed on admission, quarterly, annually, and with significant changes, and the DON stated residents with wander guards should be reassessed quarterly to determine if the device was still needed. The social worker was unable to find documentation that reassessments had been completed, and staff stated the resident should have been reassessed around the quarterly mark.
Failure to Report Suspected Abuse and Unexplained Injury
Penalty
Summary
The facility failed to report allegations and suspicions of resident-to-resident sexual abuse to the State Agency for two residents with significant cognitive impairment, and it also failed to report a potential injury of unknown source for one of those residents who had unexplained bruising and vaginal bleeding. Both residents had diagnoses including dementia and Alzheimer’s disease, and both care plans identified them as vulnerable adults who required supportive monitoring of their interactions with peers. Neither resident’s medical record contained an assessment identifying capacity to consent to a sexual relationship. R58’s record showed severe cognitive impairment, wandering, and need for assistance with dressing, grooming, and bathing. Her care plan noted cognitive loss, confusion, wandering, intrusive behavior, hallucinations or delusions, and a relationship with a male peer that required supportive monitoring to ensure interactions were safe and appropriate. R61’s record showed severe cognitive impairment, a history of wandering and checking doors, and a relationship with a female peer that also required supportive monitoring to ensure interactions were safe and appropriate. Staff were directed in both care plans to monitor interactions, observe for distress or behavioral changes, and report suspected abuse, neglect, or exploitation. Progress notes documented repeated incidents in which the two residents were found together in bed, unclothed, and asking staff to leave them alone. On one occasion, R58 had scattered bruises on both forearms in various stages of healing and stated she occasionally bumped into things and bruised easily. On another occasion, staff reported R58 had bloody discharge, but there was no further documentation. Additional notes documented bruising on R58’s thigh and another incident in which R58 and R61 were found in bed without clothing. Staff interviews showed the incidents were documented in progress notes and discussed with the team, but no event report or State Agency report was completed because the incidents were believed to be consensual and not abuse. The DON also stated the bruises were not reported because staff assumed they were caused by bumping into things and aspirin use, despite the facility policy requiring reporting of bruises of unknown origin and reporting suspected abuse within the required timeframe.
Failure to Investigate Possible Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to investigate potential resident-to-resident sexual abuse involving two residents with significant cognitive impairment, R58 and R61. R58’s annual MDS identified severe cognitive impairment, and diagnoses included Alzheimer’s disease, neurocognitive disorder with Lewy bodies, and dementia; R61’s quarterly MDS also identified severe cognitive impairment, with diagnoses including Alzheimer’s disease and dementia with psychotic disturbance. Both residents were identified in care plans as vulnerable adults, and staff were directed to report and investigate any allegations or suspected abuse, neglect, or exploitation. The record documented repeated incidents in which the residents were found together in bed unclothed or undressed, including on 10/3/25, 11/19/25, and 5/7/26. The record failed to show that the facility assessed either resident’s capacity to consent to sexual activity after any of the incidents, and the facility did not complete a formal abuse investigation to determine whether the encounters were consensual. The record also documented bruising on R58’s forearms, right anterior thigh, and inner thigh, as well as a report of bloody vaginal discharge, but there was no evidence these findings were investigated in relation to the known sexual activity. RN-A stated she did not know whether assessments or investigations had been completed, LPN-A stated she documented the 5/7/26 incident but did not complete assessments or investigations, and the DON stated no assessments had been conducted to evaluate injury or capacity to consent and that the facility did not complete a formal investigation because staff believed the encounters were consensual.
Failure to Document Pneumococcal Vaccine Education Before Consent
Penalty
Summary
The facility failed to provide education regarding the benefits and potential side effects of pneumococcal vaccination and failed to document that education was provided before obtaining a vaccination decision from the resident representative for one resident. The resident’s MDS identified the resident as an older adult with mild cognitive impairment and diagnoses including heart failure, peripheral vascular disease, diabetes, and dementia. The resident had been offered the pneumococcal vaccination but declined, and the immunization record showed prior receipt of PPSV23 and pneumococcal conjugate vaccine doses in the past. The resident’s medical record did not include evidence that the resident or the resident’s representative received education regarding pneumococcal vaccine booster guidance, and there was no indication the resident was offered the pneumococcal vaccine per CDC guidance. The immunization consent form documented that the resident’s son declined the pneumococcal vaccination by phone, but it did not show that education about the pneumococcal vaccine booster had been provided. During interview, RN-B stated the family declined by phone and that education was not mailed because most family members did not want to read it, and this was not documented. The DON stated the resident and representative need to receive all vaccination education so they understand what they are refusing or consenting to, and documentation should reflect that education.
COVID-19 Vaccination Consent and Education Deficiencies
Penalty
Summary
The facility failed to ensure an eligible resident received the COVID-19 vaccination after consent had been obtained. R30’s admission MDS identified multiple diagnoses including multiple sclerosis, CHF, rheumatoid arthritis, and Parkinson’s disease, and the resident was not up to date for COVID-19 vaccination. An Immunization Consent form dated 2/17/26 showed R30 consented to receive the COVID-19 vaccine, but the medical record did not show that the vaccine was administered or explain why it was not given. During interview, the RN responsible for infection prevention and resident vaccinations stated she was unsure why R30 had not received the vaccine and said the facility did not currently have any COVID-19 vaccine available, noting vaccines were usually ordered once per year in the fall. The facility also failed to provide current CDC COVID-19 vaccine education regarding the potential benefits and risks of vaccination before obtaining refusals for two residents. R16 and R42 were both not up to date for COVID-19 vaccination, and their Immunization Consent forms documented that their sons declined the vaccine by phone. However, the forms did not identify what education had been provided to the resident representatives. The RN stated that family members often did not want to read the education, so she did not mail education to anyone for review and did not document that it was provided. The DON stated the resident and resident representative needed to be provided all vaccination education so they could understand what they were refusing or consenting to, and that documentation should reflect their understanding of that education.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Timely Report Medication Error and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure timely reporting to the state agency (SA) regarding two separate incidents: a significant medication error and a resident-to-resident abuse event. In the first case, a resident with a care plan for high-risk pain medications received both oxycodone and morphine, resulting in altered mental status, hypoxia, and hospital admission for opioid overdose and aspiration pneumonia. The medication error was not reported to the SA until the day after the incident, as the DON delayed reporting while further investigating the significance of the error, despite facility policy requiring immediate reporting of significant medication errors. In the second case, two residents with dementia were involved in a physical altercation resulting in injuries, including a bump on the head and facial bruising. The incident occurred in the morning, but was not reported to the SA within the required two-hour timeframe. The DON acknowledged the delay, stating she reported the incident as soon as she was able after being notified by staff. Facility policy mandates immediate reporting of suspected abuse or incidents resulting in serious bodily injury, but this protocol was not followed in either event.
Failure to Implement Care Planned Fall Interventions Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that care planned interventions to reduce the risk for falls were followed for two residents, resulting in actual harm to one resident who sustained a vertebral fracture. One resident, who had a history of dementia, thoracic vertebrae fractures, muscle weakness, and osteoporosis, was assessed as high risk for falls and required assistance with mobility and transfers. Her care plan specified the use of a wheelchair for transport and the need for extensive assistance from one to two staff members during transfers. Despite these interventions, a nursing assistant attempted to ambulate the resident without a transfer belt, contrary to the care plan and family wishes, resulting in a fall and subsequent T12 compression fracture. The nursing assistant admitted to not reviewing the care plan and not being trained on it prior to the incident. Another resident with diagnoses including traumatic subdural hemorrhage, Alzheimer's disease, multiple fractures, and repeated falls was also identified as high risk for falls. His care plan required two caregivers for all transfers and ambulation, use of slip grip in his wheelchair and recliner, and other specific interventions. Despite these directives, the resident experienced multiple falls, some unwitnessed, including incidents where the slip grip was not in place and the resident was found on the floor. Staff interviews revealed a lack of awareness of the care plan interventions, with some staff unsure where to find the information or not realizing interventions were listed on the care guide. Observations and interviews confirmed that care planned fall interventions were not consistently implemented for both residents. Staff failed to use required safety equipment, such as transfer belts and slip grips, and did not always follow the specified level of assistance for transfers and ambulation. Documentation and staff statements indicated that care plans and care guides were not adequately reviewed or followed, contributing to repeated falls and injury.
Infection Control Deficiencies in Surveillance and Precaution Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete infection surveillance data and improper implementation of precautions for residents with infections and wounds. The infection prevention line listing and infection spreadsheet lacked critical information such as symptoms, treatments, and other relevant data for multiple residents, including those with norovirus and other infections. Surveillance was limited to residents who were prescribed antibiotics or antivirals, excluding those with symptoms but without a confirmed diagnosis or prescribed treatment. The infection prevention nurse was unaware of some residents' symptoms, and the surveillance process did not capture all necessary information to track, trend, and analyze infections as required by facility policy. During wound care for a resident with osteomyelitis and a stage 4 pressure ulcer, staff did not follow enhanced barrier precautions or standard precautions. Staff entered the resident's room and performed wound care without donning gowns, failed to perform hand hygiene between glove changes, and did not clean equipment after use. The care plan did not specify the need for enhanced barrier precautions, and staff demonstrated a lack of understanding regarding when to use personal protective equipment (PPE) during high-contact care activities. Observations showed that staff did not consistently use gowns or perform hand hygiene as required, and equipment used during wound care was not sanitized before being removed from the room. For another resident on contact precautions due to norovirus, the care plan did not reflect the need for these precautions. Housekeeping staff entered the resident's room, donned only gloves, and cleaned the room without wearing a gown or mask, contrary to facility policy and CDC guidelines. Staff interviews revealed inconsistent understanding and application of contact precautions, with some staff believing PPE was only necessary when providing direct care. Facility policies required the use of gowns and gloves for contact precautions and specified cleaning procedures for isolation rooms, but these were not followed during the observed events.
Failure to Address and Document Grievance Regarding Missing Resident Clothing
Penalty
Summary
The facility failed to follow its grievance policy and adequately address a grievance regarding missing clothing for a resident with severe cognitive impairment and diagnoses of Alzheimer's disease and dementia. The resident's family member reported that approximately half of the resident's clothing and slippers went missing after being brought to the nurses' desk, as instructed. The family member was not aware of the need to label the clothing and was not reimbursed for the missing items, ultimately deciding to handle the resident's laundry personally. Interviews with staff revealed that while some efforts were made to search for the missing items, such as contacting laundry and searching the lost and found, there was no formal documentation of the grievance or follow-up actions taken. Staff interviews indicated inconsistent practices regarding the reporting and documentation of missing items. The LPN recalled notifying laundry but was unaware of any formal report being made. The social services staff member stated that a grievance form was not filled out and that the family was simply asked if they wanted to file a grievance, which they declined. The DON acknowledged that there was no documentation to show that the missing items were addressed according to facility policy, which requires reporting, searching, and working with the resident or representative to determine next steps if items are not found. The lack of documentation and follow-through on the grievance process resulted in the facility's failure to honor the resident's right to voice grievances and ensure prompt resolution.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to implement effective interventions to protect two residents from resident-to-resident abuse, resulting in harm to one of the residents. Resident R2, who had a history of aggressive behavior and cognitive impairments, was involved in an altercation with Resident R1, leading to R1's transport to the Emergency Department for a scalp laceration. R2's care plan acknowledged his potential for aggression and included measures such as using a stop sign on his door and redirecting him when agitated. However, these interventions were insufficient to prevent the incident. R2's behavior had been documented as physically aggressive toward others, with incidents occurring in the days leading up to the altercation. Despite this, staff were not given specific directions for supervising R2 or R1, who was known to wander into other residents' rooms and had previously been a victim of aggression. On the day of the incident, R1 was found on the floor with a head wound after an unwitnessed fall, and video surveillance later revealed that R2 had pushed a chair R1 was holding, causing her to fall. Interviews with staff indicated a lack of clear supervision plans or new interventions following previous incidents involving R2. Staff members reported trying to keep an eye on R2 but acknowledged that redirection efforts were not always successful. The facility's abuse prevention policy required immediate safety measures to protect residents from further harm, but these measures were not effectively implemented in this case, leading to the deficiency.
Failure to Use Gait Belt Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the use of a gait belt when transferring or walking a resident, identified as R296, who was at risk for falls. R296 had moderate cognitive impairment and required maximum assistance with transfers and ambulation. The care plan for R296 included the use of a gait belt during ambulation and transfers, but this was not adhered to during the incident. R296 experienced a fall while being assisted in the bathroom, resulting in a lumbar compression fracture. The incident occurred when a nursing assistant was assisting R296 in the bathroom. R296 stood up from the toilet without issues, but subsequently fell forward, hitting her head on a safety bar. The nursing assistant did not use a gait belt during this transfer, which was against the facility's policy and R296's care plan. The fall was witnessed, and R296 was unresponsive for approximately ten minutes before being sent to the emergency room for evaluation. Following the fall, R296 experienced significant pain and was diagnosed with a lumbar compression fracture. The resident's condition deteriorated, leading to increased pain and discomfort, refusal to eat, and eventually admission to hospice care. R296 passed away shortly after the incident. Interviews with staff revealed that the use of a gait belt was expected during transfers and ambulation, but it was not utilized in this case, contributing to the resident's fall and subsequent injury.
Failure to Offer Updated Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that recommended pneumococcal vaccinations, as outlined by the CDC, were offered and/or provided in a timely manner to four out of five residents reviewed for immunizations. The residents involved had various medical conditions, including cerebral infarction, Alzheimer's disease, diabetes, kidney failure, stage four pressure ulcer, atrial fibrillation, heart failure, and dementia. Despite having received previous pneumococcal vaccinations (PPSV23 and PCV13), there was no evidence in their medical records that the newer recommended PCV15 or PCV20 vaccinations had been offered or administered. Interviews with facility staff revealed that the registered nurse responsible for infection prevention was aware that the residents were due for updated pneumonia vaccinations but had not yet offered them. The nurse had recently resumed the infection preventionist role and was attempting to catch up on various tasks, including offering the PCV15 or PCV20 vaccinations. The Director of Nursing was unaware that these vaccinations were not being offered, despite CDC recommendations. Additionally, the facility's policy on pneumococcal vaccines had not been updated to reflect the new CDC guidelines, contributing to the oversight.
Failure to Document Rationale for Continued Antidepressant Use
Penalty
Summary
The facility failed to ensure that a provider documented a thorough rationale for the continued use of antidepressant medications for one resident. The resident had active physician orders for sertraline and trazadone, but the medical record lacked evidence of depression symptoms. The consulting pharmacist recommended a trial reduction of the medications, but the primary physician responded that a dose reduction was contraindicated without providing further documentation or justification in the medical record. Interviews revealed that the registered nurse was unaware of the need for rationale to deny a gradual dose reduction and did not question the physician's decision. The Director of Nursing acknowledged struggles with certain providers addressing pharmacy recommendations and had discussed the issue with the providers' group. The consulting pharmacist confirmed that he had made recommendations to taper the medications but had not followed up due to other concerns with the resident's condition. The Medical Director was aware of the issue and planned to address it with the providers.
Failure to Implement Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a process for gradual dose reduction (GDR) or adequate medical justification for the continued use of psychotropic medications for a resident. The resident, identified as having moderate cognitive impairment, was receiving daily doses of sertraline and trazodone, despite the absence of documented symptoms of depression. A consultant pharmacist recommended a trial reduction of these medications, but the primary physician indicated that a dose reduction was contraindicated without providing further documentation or justification in the resident's medical record. Interviews with facility staff revealed a lack of awareness and follow-up regarding the pharmacist's recommendations. The registered nurse was unaware of any further discussion about the need for rationale to deny a GDR since the initial recommendation. The director of nursing acknowledged ongoing issues with providers not addressing pharmacy recommendations and had recently discussed these expectations with the providers. However, there was no clear nursing process identified to address GDRs or obtain rationale from providers, and the facility did not provide a policy for psychotropic medication dose reduction when requested.
Failure to Securely Store Medications for a Resident
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications for a resident with moderate cognition and multiple health conditions, including stage IV pressure ulcers and type 2 diabetes. During an observation, it was noted that Vashe (Dakin's) solution wound cleanser and Nystatin powder were left unsecured on the dresser in the resident's room. The resident's medical records included an order for the wound cleanser but did not have any orders for the Nystatin powder. Additionally, there was no assessment or care plan indicating that medications should be stored at the bedside. Interviews with the resident and nursing staff revealed that the medications were routinely left in the room for dressing changes, and the resident was unsure of the medication names. A Licensed Practical Nurse confirmed the presence of an order for the wound cleanser but not for the Nystatin powder, and acknowledged that medications should not be left unsecured. A Registered Nurse also confirmed awareness of the unsecured medications and stated that they should be stored safely and out of reach. The facility's policy on self-administration of medications requires that medications be stored securely, which was not adhered to in this case.
Failure to Provide Timely INR Results for Resident on Warfarin
Penalty
Summary
The facility failed to provide timely INR level results for a resident, identified as R52, who was on warfarin sodium, a blood-thinning medication. R52 had multiple diagnoses, including end-stage renal disease, heart failure, and vascular disease, and was on anticoagulant medication. The care plan for R52 included monitoring for symptoms such as dizziness and irregular heartbeat and required staff to administer medications and draw labs as ordered, reporting any abnormalities promptly. However, there was a delay in communicating the INR results to the medical provider, which was crucial for managing the resident's condition. On several occasions, the INR results for R52 were not communicated promptly to the medical provider. For instance, the INR result obtained on 7/29/24 was not faxed to the medical provider until 7/30/24, and the response was not documented in the electronic medical record (EMR) until later. The registered nurse (RN) responsible for R52's care admitted to forgetting to enter the response into the EMR and did not investigate the cause of the subtherapeutic INR result. This oversight potentially placed the resident at risk for a blood clot or stroke, as the INR was below the therapeutic range. Interviews with facility staff, including the trained medication aide, licensed practical nurse, registered nurse, assistant director of nursing, and director of nursing, revealed inconsistencies in the process of handling INR results. The facility's policy did not adequately address the timely reporting of INR results or provide clear guidelines for staff on how to proceed when a response from the medical provider was not received. The medical director expressed dissatisfaction with the current fax system and emphasized the need for guidelines to ensure timely communication of INR results, especially when they are out of range.
Failure to Implement Enhanced Barrier Precautions for Residents with Catheters
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with indwelling catheters, leading to a deficiency in infection prevention and control. Resident 1, who had severe cognitive impairment and an indwelling catheter, was not identified as being on EBP in their care plan. Observations revealed that there was no personal protective equipment (PPE) cart in or outside Resident 1's room, and staff did not wear gowns while providing care. Similarly, Resident 69, with moderate cognitive impairment and an indwelling catheter, also lacked EBP implementation, as evidenced by the absence of a PPE cart and staff not wearing gowns during care activities. Interviews with staff, including a nursing assistant and the facility's infection preventionist, highlighted a lack of clarity and understanding regarding the implementation of EBP. The infection preventionist acknowledged that EBP was intended for residents with indwelling medical devices, such as catheters, but could not explain why it was not applied to Residents 1 and 69. The facility's policy on EBP, dated March 28, 2024, specified that EBP should be used for residents with indwelling medical devices to decrease the transmission of multi-drug resistant organisms, yet this was not adhered to for the residents in question.
Failure to Complete Significant Change MDS for Two Residents
Penalty
Summary
The facility failed to complete a significant change in status Minimum Data Set (MDS) for two residents, leading to deficiencies in care planning and service provision. Resident R64, who had moderate cognitive impairment and required varying levels of assistance with daily activities, experienced a decline in mobility and became dependent on staff for transfers and unable to ambulate. Despite these changes, a significant change MDS was not completed. Interviews revealed that the registered nurse responsible for R64's MDS relied on notifications from a licensed practical nurse, who failed to recognize the need for a significant change assessment due to ongoing therapy. Similarly, Resident R296, who had moderate cognitive impairment and required substantial assistance with daily activities, experienced a significant decline in mobility and was admitted to hospice care following a fall that resulted in a lumbar fracture. Despite these significant changes, a significant change MDS was not initiated. The registered nurse responsible for R296's MDS was unaware of the need for a significant change assessment, and the licensed practical nurse did not schedule it, even though hospice admission was recognized as an automatic trigger for such an assessment. The director of nursing confirmed the expectation for significant change MDS assessments to ensure accurate care planning.
Failure to Supervise Resident with Marijuana Use
Penalty
Summary
The facility failed to develop and implement interventions to ensure adequate supervision for a resident (R5) who had multiple incidents of unsafe behavior related to marijuana use. R5 had a history of schizo-affective disorder, dementia, mood disturbance, and anxiety, and was identified as having moderate cognitive impairment. Despite having a care plan and a marijuana use contract in place, R5 was frequently observed using marijuana unsupervised, leading to multiple falls and unsafe behaviors such as sleepwalking and entering other residents' rooms. R5's care plan indicated that she should not be unaccompanied when ambulating outside the facility due to her marijuana use, but staff interviews revealed that this directive was not consistently followed. Staff members were aware of R5's marijuana use but did not monitor her adequately, allowing her to go to the smoking area unsupervised even when she appeared intoxicated. R5's progress notes documented several instances where she was found in unsafe conditions, such as being on the floor after smoking marijuana or being inadequately dressed while outside. Interviews with various staff members, including nursing assistants and registered nurses, indicated a lack of clear communication and understanding of R5's fall interventions and marijuana use contract. Staff members were not consistently monitoring R5's marijuana use or ensuring her safety when she went outside to smoke. The facility's director of nursing acknowledged that there was no designated person to supervise R5, and the facility did not have a specific marijuana use policy in place. This lack of supervision and clear guidelines contributed to R5's repeated falls and unsafe behaviors.
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What surveyors actually found near you
We read the 17 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Crookston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair Meadow Nursing Home | 22.5 mi | ★★★★★ | 12 | 0 |
| Valley Senior Living On Columbia | 23.9 mi | ★★★★★ | 1 | 0 |
| Woodside Village | 24.4 mi | ★★★★★ | 4 | 0 |
| Oakland Park Communities, Inc. | 29.4 mi | ★★★★★ | 19 | 0 |
| Thief River Care Center | 29.6 mi | ★★★★★ | 12 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.