St. Joseph's Villa, Inc.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number: 175 NAC 12.004.02 Based on observation, interview, and record review, the facility failed to ensure staff performed proper hand hygiene during food preparation and between glove changes, ensure expired foods were discarded, ensure food brought in by family was labeled and dated, and ensure staff food was stored separately from residents' food in the unit refrigerators to prevent potential foodborne illness. This had the potential to affect all 52 residents in the facility who consume food prepared in the kitchen.A.An observation during the initial kitchen tour on 8/6/2025 from 8:20 AM to 9:25 AM revealed the following:One box of thickened hot cocoa mix with expiration date 5/4/2025.Two bottles of honey thickener with expiration date 6/6/2025.Upright freezer with an open bag of chicken strips not dated or sealed.In the dry storage, two totes of Panko breadcrumbs opened 5/6/2025 with no expiration date found, and six boxes of chicken noodle soup with expiration date of 4/2025.An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F)The facility failed to put in new interventions in the comprehensive care plan to prevent falls for 2 (Resident 2 and Resident 6) out of 3 sampled residents. The facility census was 52.Licensure Reference Number 175 NAC 12-006.09(F) A record review of the admission Record revealed Resident 2 was admitted to the facility on [DATE] with diagnoses of Adult failure to thrive (a collection of symptoms that include weight loss, decreased appetite, fatigue, and cognitive decline), Diarrhea (frequent, loose, or watery bowel movements), Constipation (a condition where bowel movements are infrequent or difficult to pass, often characterized by hard, dry stools), Urinary tract infections (an infection in any part of the urinary system), insomnia (trouble falling asleep, staying asleep (usually through the night), or waking up too early in the morning), Arial fibrillation (a heart condition where the heart beats irregularly and rapidly), and Hypothyroidism (when your thyroid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY License Reference Number 175 NAC 12-006.09 (H)(iv)(5)The facility failed to monitor bowel status and administer PRN meds to prevent constipation for three residents (Resident 2, 41 and 52) out of six sampled residents. The facility census was 52.Findings: A. A record review of Resident 41’s “Minimum Data Set” (MDS)(this comprehensive assessment evaluates each resident's functional capabilities) dated 4/28/2025 revealed a brief interview for mental status (BIMS) score of 13 which indicated the resident’s cognitive function is considered intact and Resident 41 was dependent for toileting. A record review of Resident 41’s “Care Plan” dated 8/6/2025 revealed a diagnosis of constipation without interventions associated with prevention of constipation. A record review of Resident 41’s “Bowel Monitoring Form” dated 4/1/2025-8/12/2025 revealed no bowel movements documented 4/13/2025-4/18/2025 (six days no bowel movement), 5/3/2025-5/8/2025 (six days no bowel movement), 5/25/2025-6/4/2025 (11 days no bowel movement),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(I)Based on observation, interview, and record review, the facility failed to implement interventions (action taken to improve the situation) to prevent potential falls for 1 (Resident 42) of 3 sampled residents. The facility census was 52.Findings are: A record review of the facility's Fall Prevention Program dated 02/28/2025 revealed that when a resident had a fall, the facility would review the resident's care plan and add an intervention before the end of the shift. The resident's risk factors and environmental hazards would be evaluated when developing the resident's care plan and interventions would be monitored for effectiveness. The care plan would be revised as needed. A record review of Resident 42's Clinical Census dated 08/11/2025 revealed the resident was admitted to the facility on [DATE].A record review of Resident 42's Medical Diagnosis dated 08/11/2025 revealed the resident had diagnoses of Paranoid Schizophrenia (delusions and seeing things), Morbid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g)Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 53) of 1 sampled resident's oxygen order was followed. The facility census was 52.Findings are:A record review of the facility's Oxygen Concentrator policy dated 8/11/2025 revealed oxygen was to be administered under order of the physician. The nurse would verify the orders for the flow rate and turn the unit on to the desired flow rate.A record review of the facility's Oxygen Administration policy dated 8/11/2025 revealed oxygen was administered consistent with professional standards of practice. Oxygen was administered under the orders of a physician.A record review of Resident 53's Clinical Census dated 08/11/2025 revealed the resident was admitted to the facility on [DATE].A record review of Resident 53's Medical Diagnosis dated 08/11/2025 revealed the resident had diagnoses of Chronic Respiratory Failure (long term breathing disorder resulting in low oxygen),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18(B) Licensure Reference Number 175 NAC 12-006.18(D) The facility failed to sanitize the blood glucose monitoring machine prior to and after obtaining a blood sugar on three (Resident 41, 43. and Resident 50) out of three sampled residents, perform proper hand hygiene while administering medications, keep Resident 53's oxygen nasal cannula off the floor and concentrator filter clean to prevent potential cross contamination. The facility census was 52. Findings are: Findings: A. A record review of the Facility’s “Glucometer Disinfection” policy dated 19/2000 with a review date of 6/2025 revealed: The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. If the manufacturers are unable to provide information specifying how the glucometer should be cleaned and disinfected, the meter should not be used for multiple patients. The glucometers should be disinfected with a wipe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to report a fall resulting in serious bodily injury to the state agency within the required time frame for 2 residents (Resident 1 and Resident 4) of 3 residents sampled, and the facility failed to ensure the written investigations were submitted within five working days for 2 residents (Resident 1 and Resident 2) of 3 residents sampled. The facility census was 54. Findings are: A record review of the facility's Abuse, Neglect and Exploitation policy dated 03/21/2024 revealed that facility procedures include reporting of all alleged violations to the state agency and/or Adult Protective Services (APS) immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Further review of the policy revealed the Administrator would report the results of the investigation when final within 5 working days of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18(B) Licensure Reference Number 175 NAC 12-006.18 (D) Based on record review, observatations and interview, the facility failed to provide Enhanced Barrier Precautions(EBP, involves wearing specific personal protective equipment (PPE), such as gowns and gloves, during high-contact care activities) to Residents 13, 14, 21, 25, 41 and 50, and the facility failed to provide storage/cleaning to the respiratory equipment to prevent cross contamination for Residents 41 and 28 and the facility failed to perform hand hygiene cares for wound care and catheter cares for Resident 14 and Resident 25 to prevent cross contamination for 4 sampled residents out of 24 sampled residents. The facility census was 47. Findings are: A. A record review of Resident's on Enhanced Barrier Precautions with no dated noted provided by the facility upon entry revealed that Resident 13, 50, 14, 41, 25 ,21 were on the list for Enchanced Barrier Precautions. An observation on 08/28/24 at 09:22 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09B Based on record review, observation, and interview, the MDS (Minimum Data Set, a federally mandated assessment used for care planning) did not reflect the use of a C-PAP (continuous positive airway pressure, a machine that treats sleep-related breathing disorders by keeping airways open during sleep) for 1 (Resident 28) of 12 sampled residents. The facility census was 47. Findings are: A record review of the admission Record with a list of diagnosis of a printed date of 8/29/24 revealed diagnosis of Paranoid Schizophrenia (is characterized by paranoia, delusions, and hallucinations), Chronic Respiratory Failure with Hypercapnia(a condition that occurs when the body has too much carbon dioxide (CO2) in the blood and can't get rid of it.), Morbid (severe) obesity with Alveolar Hyperventilation(A decrease in the body's ability to ventilate), obesity (an excessive accumulation of body fat that can negatively impact health), obstructive sleep apnea (a sleep condition that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and interview, the facility failed to ensure that PASARR (readmission Screening Resident Reviews) for individuals with a mental disorder or intellectual disability were accurately completed to determine if a Level 11 PASARR review was warranted for 1 (Resident #28) of 12 sampled residents. The facility census was 47. Findings are: A record review of Resident 28 admission MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning), dated 7/17/24, revealed that Resident 28 had diagnoses including Schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors). Further review revealed that Resident 28 had not been evaluated by Level 11 as indicated with a serious mental illness( health conditions involving changes in emotion, thinking or behavior (or a combination of these) diagnosis. A record review of the current PASRR evaluation dated 7/1/24 revealed that Section 111 PASRR Conditions:1. Mental Illness or suspected Mental Illness (all that apply) was answered No mental health diagnosis is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D6(7) Based on interviews, record reviews, and observations, the facility failed to obtain a physician order for 1 (Resident 25) of 1 sampled resident continuous positive airway pressure (CPAP, is a machine that uses mild air pressure to keep breathing airways open while you sleep). The facility census is 47. Record review of Resident 25's admission Record revealed Resident 25 admitted on [DATE]. Record review of MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 6/6/24 revealed in Section C: Resident 25's BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) scored 14. Section O revealed using a non-invasive ventilator. Record review on 8/28/24 revealed there was no order for a CPAP. Record review of a Physician referral form dated 8/31/24 revealed diagnosis for CPAP is Obstructive Sleep…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to properly store food and failed to keep a clean environment in the kitchen to prevent the potential for cross contamination and food borne illness. This had the potential to affect 40 of 40 residents that ate food prepared in the facility kitchen. The facility census was 40. Findings are: Observation on 10/2/23 from 8:25 AM to 9:00 AM during initial kitchen tour revealed the following: -dust on top of ice machine -white build up inside of ice machine -plastic bag of powdered sugar opened -opened plastic bag with dark brown sticky substance on it with opened package of sugar free lemon gelatin dessert mix - dark brown crumbs on tray holding packages of sugar free lemon gelatin dessert mix -food particles and dust behind stoves/ovens and metal rack for tray -dirt build up around baseboard throughout main kitchen and dishwashing areas -splattered dried food on back wall and lower cupboards in prep area Observation on 10/3/23 from 2:33 PM to 2:45 PM during final…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, record review and interview; the facility staff failed to perform hand hygiene to prevent the spread of infection and prevent cross contamination during peri-care for Resident 7 and wound care for Resident 3. This affected 2 of 3 sampled residents. Facility census was 40. Findings are: A. Observation on 10/3/2023 at 12:05 PM of peri-care completed on Resident 7 by Medication Aide (MA)-D and Nursing Assistant (NA) -C, with Director of Nursing (DON) present, revealed the following: Resident 7 was placed on the bed pan. At this time, MA-D applied soap to their hands, lathered for 7 seconds, then rinsed the soap off with water. NA-C applied soap to their hands, lathered for 15 seconds, then rinsed soap off of their hands with water. NA-C and MA-D applied gloves. Resident 7 was positioned to their right side and the bedpan removed by MA-D, along with the protective dressing to Resident 7's coccyx. MA-D and NA-C did not remove their soiled gloves and hand hygiene was not completed. MA-D performed peri-care, applied cream…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.