St Dominic Village Rehabilitation and Nursing Cent

In the surveyor’s words

From the most serious findings on record at St Dominic Village Rehabilitation and Nursing Cent, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 5, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF851Jun 25, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF921Aug 11, 2026

  Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 3 of 4 residents (Residents #1, #2 and #5), 2 of 4 common areas (dining room and front TV room), 1 of 4 nurse's stations (Station 1) and vacant rooms in 1 of 4 halls (room [ROOM NUMBER], #102 and #103) in that: The facility failed to maintain the roof when ceiling tiles broke on 08/11/2026, causing flooding in Resident #2 and #5's bedrooms, the dining room, in the hallway near Station 1 and rooms #101, #102 and #103. […]

• No harm, potential for more than minimal, patternF759Jun 25, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF656Dec 17, 2025

  Based 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. - The facility failed to document Resident #2's fall from 8/29/25, and interventions put in place, which included a low bed, and a clutter free area.- The facility failed to document Resident #3's falls from 11/17/25 and 11/27/25, and interventions put in place, which included a low bed.- The facility failed to document… […]