St Dominic Villa

In the surveyor’s words

From the most serious findings on record at St Dominic Villa, in the surveyor’s own words.

• Immediate jeopardy, isolatedF700Dec 22, 2025

  1 of 9 reviewed for bedrailsBased on interview and record review, the facility did not ensure other alternatives were tried prior to installing/utilizing bed rails, failed to accurately assess the risk of possible entrapment, failed to identify and recognize the use of an air mattress with bed rails increases the risk for entrapment, failed to re-assess and obtain an updated consent after the installation of an air mattress with bed rails, and care plan the need and use of bed rails for 1 of 9 residents (R11) reviewed for bed rails.R11 did not have alternatives attempted prior to the facility installing and utilizing bed rails.R11's bed rail assessment was not completed accurately.R11's bed rail assessment and consent form were not updated after the installation of an air mattress.R11's… […]

• Immediate jeopardy, isolatedF686Aug 15, 2024

  Based on observation, interview, and record review, the facility did not ensure that 2 of 2 residents (R) reviewed for pressure injuries (PI) (R36 and R8) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R36 was at risk for PI development. R36 developed multiple stage 3 PI's. The facility failed to evaluate the effectiveness of current interventions R36 had in place. The facility did not reposition R36 for several hours, did not find PI's until they were at a Stage 3, missed weekly wound treatments, and did not provide proper infection control measures during wound dressing change. R8 was at risk for PI development. R8 developed multiple stage 3 PI's. […]

• Immediate jeopardy, isolatedF689Feb 12, 2024

  Based on observation, interview, and record review, the facility did not ensure that each resident's environment remains as free of accident hazards as possible for 1 of 1 residents (R1). R1 resided in the facility's memory care unit and has a history of tossing her leg onto the heat register next to her bed. On 1/15/24, R1 was found to have placed her foot on the heat register next to her bed. This resulted in burns to R1's left lateral foot (full thickness), left foot (undetermined thickness) and right foot (undetermined thickness) that required physician intervention. […]

• Immediate jeopardy, isolatedF600Oct 6, 2023

  Based on observation, interview, and record review the facility failed to ensure that 5 of 13 sampled residents (R2, R10, R13, R9, R14) were free from neglect. Numerous staff expressed concerns about low staffing levels and not being able to provide all needed care because there isn't enough staff. R2 had a history of recurrent Urinary Tract Infections (UTIs). The facility failed to follow the physician orders for monitoring R2's output. The facility does not have evidence that staff provided catheter care to R2 on 4/21/23. On 4/21/23 at 5:00 PM, the facility called 911 after finding R2 unresponsive while delivering her supper tray. Emergency Medical Services (EMS) found R2 covered with ants. […]

• Actual harm, isolatedF689Aug 15, 2024

  Based on interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accidents (R54). R54 was a known fall risk and the facility did not follow her plan of care, resulting in a fall with fracture. Findings include: The facilities fall policy states the following: *Prevention measures are put in place to reduce the occurrence of falls in risk of injury from falls. […]