Villa St. Vincent
VILLA ST. VINCENT in CROOKSTON, MN — inspection on June 4, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
door to come inside was locked and so the resident would not have access back into the building.
had questioned if there was some type of call, they could give the resident to use outside or if the
could lock but a resident outside could still get in. SW-A had brought up R42's complaint to the interdisciplinary team (IDT) and they were working on it, attempting to figure out a way more cognitively intact residents could go outside without supervision.
The other problem was there was no shade.
The facility had thought of putting an umbrella up but there was a concern it could blow over in the wind. On 6/4/26, at 1:44 p.m. a joint interview was conducted with the administrator and the director of nursing (DON).
The DON stated the facility recently updated their locks to make the building more secure.
The facility had also identified a concern with the current staff practices of allowing residents to out into the secured courtyard unsupervised.
The ground was uneven and an accident risk, so the facility implemented that staff needed to be out with the residents in that area to ensure safety. It had always been that way, and staff had just gotten lax on the rule.
They had not had a chance to evaluate each resident to see if they could be deemed safe to go out to the courtyard.
One resident had recently fallen into the courtyard and because of that fall, it was discovered that staff were allowing resident's go to outside alone. If R42 were to wheel out there and go off the sidewalk, there was a risk he could tip his chair.
The facility did not have therapy or nursing to assess how safe residents were when they were outside.
The facility policy Resident Rights and Notification of Resident Rights, last reviewed 8/28/25, identified the facility acted to protect and ensure the rights of residents.
Social services or designee would inform the residents of the Resident Rights at the time of admission and with changes to regulatory statute.
Any time state or federal laws relating to resident rights or facility rules changed during the residents' stay, the residents would be promptly informed of the changes.
The policy listed 45 resident rights which included exercise of rights, planning and implementing care, accommodation of needs, and grievances.The facility policy Chemical and Physical Restraints last reviewed 8/31/23, identified medical symptoms that warrant the use of restraints would be documented in the resident's medical record.
Before a restraint was used the IDT would determine the presence of a medical symptom that required a restraint and how the restraint would treat the medical symptom, protect the resident's safety and assist the resident in attaining or maintaining their highest practicable level of physical and psychological wee-being.
Alternative to the restraint and the risk benefits would be discussed with the residents.
For the residents to be fully informed, the IDT would explain the context of the resident's condition and circumstances, and the potential risks and benefits of options under consideration.
Alternatives would be considered and discussed with the resident or resident representative.
245484 06/04/2026
Villa St Vincent 516 Walsh Street Crookston, MN 56716
Based on the assessment, the residents may be provided with equipment to aid in safety (such as a smoking apron) when they chose to smoke while off campus.
The assessment further identified the facility would consult with the resident and/or the resident representative for alternate assistance to use off campus smoking options.
245484 06/04/2026
Villa St Vincent 516 Walsh Street Crookston, MN 56716
female or male.
There was an incident SW-A had witnessed when another male resident, not R61, had
jeopardy to resident health or safety
245484 06/04/2026
Villa St Vincent 516 Walsh Street Crookston, MN 56716
resident signaling device.
All residents determined at risk by the IDT team for wandering off units or
for continued need.
245484 06/04/2026
Villa St Vincent 516 Walsh Street Crookston, MN 56716
state agency (SA). R58's bruises had never been reported because she walked around holding on to
complete a VA report.
The DON was not sure if she had been notified of the bruises found on R58's
would develop an individual abuse prevention plan for each vulnerable adult who received services in the facility.
The plan would include the resident's susceptibility to abuse, risk of abusing other vulnerable adults and specific measures to be taken to minimize the risk of abuse.
Resident incident reports and medical records would be routinely monitored for indicators of possible abuse.
Any allegations involving abuse would be investigated whether they caused injury or harm or no injury or harm.
Staff would notify the facility administrator, DON and director of social services. If the event involved abuse or resulted in serious bodily injury, staff were required to report to the SA immediately, but no later than two hours after forming the suspicion. If the event did not involve abuse and did not result in bodily injury, staff were required to report to the SA no later than 24 hours after forming the suspicion.
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Villa St Vincent 516 Walsh Street Crookston, MN 56716
abuse for 2 of 2 residents (R58, R61) reviewed for abuse.
The facility became aware of repeated
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.
Findings include:R58R58's annual Minimum Data Set (MDS) dated [DATE] identified severe cognitive impairment.
Diagnoses included Alzheimer's disease, neurocognitive disorder with Lewy bodies, and dementia.R58's care plan identified cognitive loss related to dementia, confusion, wandering, hallucinations or delusions, and identified R58 as a vulnerable adult.
Staff were directed to report and investigate any allegations or suspected abuse, neglect, or exploitation.R58's progress notes identified the following:On 10/3/25, R58 and R61 were found together in bed unclothed and requested privacy.On 11/19/25, staff again found R58 and R61 undressed in bed together.On 5/7/26, staff found R58 and R61 in bed together without clothing.The record failed to contain evidence the facility assessed either resident's capacity to consent to sexual activity following any of the incidents.The record further identified:On 10/9/25, scattered bruises in various stages of healing were noted on both forearms.On 12/11/25, R58 reported bloody vaginal discharge.On 3/5/26, bruising was noted to the right anterior thigh and inner thigh.The record failed to contain evidence the facility investigated whether the bruising or report of vaginal bleeding were related to the known sexual activity involving R58 and R61.R61R61's quarterly MDS dated [DATE] identified severe cognitive impairment.
Diagnoses included Alzheimer's disease and dementia with psychotic disturbance.R61's care plan identified cognitive loss related to dementia and identified R61 as a vulnerable adult.
Staff were directed to observe for signs of distress, coercion, confusion, or behavioral changes related to interactions with R58 and to report and investigate any allegations or suspected abuse, neglect, or exploitation.R61's progress notes identified staff found R58 and R61 unclothed together on 10/3/25, 11/19/25, and 5/7/26.The record failed to contain evidence the facility assessed R61's capacity to consent to sexual activity or completed an abuse investigation to determine whether the encounters were consensual.On 6/2/26 at 10:11 a.m., registered nurse (RN)-A stated she did not know if any investigation or assessments had been completed following the incidents involving R58 and R61. RN-A stated she had not documented assessments related to the incidents or the bruising identified on R58.On 6/2/26 at 11:01 a.m., licensed practical nurse (LPN)-A stated she documented the 5/7/26 incident but did not complete assessments/investigations on either resident and was unsure whether any assessments/investigations had been completed by others.On 6/2/26 at 11:57 a.m., the director of nursing (DON) stated no assessments had been conducted following the incidents to evaluate physical injury or assess the residents' judgment or capacity to consent.
The DON stated the facility believed the encounters were consensual based on the residents' behaviors and no further investigation had been conducted and the facility staff knew the incidents were consensual by how the residents behaved and their actions and no further investigation had been conducted.
The DON further stated the facility did not complete a formal investigation process. At 5:00 p.m., the DON stated the facility did not conduct a formal investigation because staff believed the incidents were consensual.
The DON further stated R58's bruising had not been investigated, and she was unaware of the reports of inner thigh bruising and vaginal bleeding.The facility's Abuse Prevention Plan directed staff to investigate allegations involving abuse and to monitor incident reports and medical records for indicators of possible abuse
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Villa St Vincent 516 Walsh Street Crookston, MN 56716
Findings included:R42's Comprehensive Minimum Data Set (MDS) dated [DATE], identified R42 as [AGE] years old, had mild cognitive impairment and diagnoses that included heart failure, peripheral vascular disease, diabetes, and dementia. R42 was offered the pneumococcal vaccination but declined.R42's Immunization Report dated 3/23/26, identified R42 received pneumovax (PPSV23) on 5/20/09, and a pneumococcal conjugate vaccine (Prevnar 13) on 5/20/09. R42's Immunization Report dated 8/30/23, identified R42 received pneumovax (type unknown) on 4/28/14, and a pneumococcal conjugate vaccine (Prevnar 13) on 9/8/16. R42's medical record did not include evidence R42 or R42's representative received education regarding pneumococcal vaccine booster and there was no indication R42 was offered the pneumococcal vaccine per CDC guidance.R42's Immunization Consent form dated 3/23/26, identified R42's son declined the pneumococcal vaccination by phone.
However, the form did not include evidence R42 or R42's representative received education regarding pneumococcal vaccine booster per CDC guidance.
During an interview on 6/3/26 at 10:24 a.m., RN-B stated R42's family declined the pneumococcal vaccination by phone.
Most family members didn't want to read the education, so RN-B didn't mail any education to anyone for review, nor did she document that.
During an interview on 6/4/26 at 8:50 a.m., the director of nursing (DON) stated the resident and the resident representative need to be provided with all the education regarding vaccinations to ensure they understand what they are refusing or consenting to.
Documentation should reflect their understanding of that education.The facility policy Pneumococcal Vaccines for Residents dated 1/9/25, identified the facility would provide education and administration of the PPSV23 and PCV13 to the residents according to CDC recommendations. CDC now recommended pneumococcal conjugate vaccine (PCV15 or PCV20) for adults who never received a prior pneumococcal conjugate vaccine (PCV13) if they are 50 years or older and have certain chronic medical conditions or other risk factors.
For adults who have only received PCV13 but not PPSV23, CDC recommends vaccine providers give PPSV23 as previously recommended.
The infection preventionist or designee will provide the resident and/or the responsible party
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Villa St Vincent 516 Walsh Street Crookston, MN 56716
Review of the medical record through 6/4/26 failed to identify the vaccine had been administered or documentation explaining why it was not administered despite approximately three, and one-half months having elapsed since consent was obtained.EducationR16R16's admission MDS dated [DATE], identified R16 as [AGE] years old, had a mild cognitive impairment and diagnoses that included CHF and atrial fibrillation (irregular heartbeat).
R16 was not up to date for COVID-19 vaccination.
The MDS did not identify if R16 was offered a COVID-19 vaccination.R16's Immunization Consent form dated 3/23/26, identified R16's son declined the COVID-19 vaccination by phone.
However, the form failed to identify the education provided to R16's son.R42R42's admission MDS dated [DATE], identified R42 as [AGE] years old, had a mild cognitive impairment and diagnoses that included heart failure, peripheral vascular disease, diabetes, and dementia. R42 was not up to date for COVID-19 vaccination.
The MDS failed to identify if R42 was offered a COVID-19 vaccination.R42's Immunization Consent form dated 3/23/26, identified R42's son declined the COVID-19 vaccination by phone.
However, the form failed to identify the education provided to R42's son.
During an interview on 6/3/26 at 10:24 a.m., RN-B stated R16 and R42's family declined the COVID-19 by phone.
Most family members didn't want to read the education, so RN-B doesn't mail any education to anyone for review, nor does she document that.
During an interview on 6/4/26 at 8:50 a.m., the director of nursing (DON) stated there was no documentation in R30's medical record that reflected R30 was given the COVID-19 vaccination nor why R30 had not received it.
The DON stated should have received the vaccination as R30 had consented to.
The DON also stated the resident and the resident representative need to be provided with all the education regarding vaccinations to ensure they understand what they are refusing or consenting to.
Documentation should reflect their understanding of that education.The facility policy COVID-19 Vaccine and Booster for Residents dated 5/11/21, identified the facility would assure all residents that are eligible are offered the COVID-19 vaccination and booster doses when available.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.