Inspection Reports for St. Joseph Villa Nursing and Rehabilitation

The notice serves to inform the facility of disciplinary action due to violations found during a survey dated August 22, 2024, specifically related to failure to transfer residents in a manner to prevent injury.

The facility was found to have violated licensure regulations concerning accidents and resident safety, resulting in probation and requirements to submit a Plan of Correction and ongoing reports during the probation period.

The document is a Nursing Home Licensure Renewal Application and related certification documents for St. Joseph Villa Nursing Center, indicating the renewal of the facility's license.

The documents certify that St. Joseph Villa Nursing Center meets statutory requirements for skilled nursing facility licensure and includes details about ownership, services, and capacity. No deficiencies or inspection findings are reported.

The document is a Nursing Home Licensure Renewal Application and related licensing and certification documents for St. Joseph Villa Nursing Center, submitted to renew the facility's license and endorsement for the Alzheimer's Special Care Unit.

The documents confirm that St. Joseph Villa Nursing Center meets statutory requirements for licensure as a skilled nursing facility with a specialized Alzheimer's care unit. The renewal application includes detailed ownership, officer, and stockholder information, and the facility's maximum licensed capacity is 184 beds.

An unannounced visit was conducted to investigate a complaint regarding the facility's failure to use appropriate interventions to prevent falls and injuries.

The facility was found to be in compliance with regulatory requirements, using appropriate interventions to prevent falls and injuries as confirmed by observations, record reviews, and interviews.

The complaint alleged failure to use appropriate interventions to prevent falls and injuries. The investigation found the facility compliant with all regulatory requirements related to these allegations.

An unannounced visit was conducted to investigate a complaint at St. Joseph Villa Nursing Center on June 19-20, 2019, regarding failure to provide care to prevent pressure sores, failure to provide nutrition to prevent weight loss, and failure to identify change in condition.

The facility failed to provide care and treatment to prevent pressure sores and failed to identify a change in condition, including failure to notify the practitioner and responsible party and failure to obtain treatment orders and nutritional evaluation for pressure ulcers. The facility did provide nutrition to prevent weight loss, so no violation was found on that issue.

The complaint alleged failure to provide care and services to prevent pressure sores, failure to provide nutrition to prevent weight loss, and failure to identify change in condition. The investigation substantiated failure to prevent pressure sores and failure to identify change in condition, but did not substantiate failure to provide nutrition to prevent weight loss.

An unannounced visit was conducted to investigate a complaint that the facility failed to follow practitioner's orders for oxygen administration.

The facility failed to ensure one sampled resident was provided oxygen in accordance with physician orders during a doctor's appointment, resulting in the resident being admitted to the hospital. The facility was cited for this deficiency and required to submit a plan of correction.

The complaint alleged the facility failed to follow practitioner's orders for oxygen administration. The allegation was substantiated as the facility did fail to provide oxygen to one resident during transport to a doctor's appointment, violating Federal regulation F695 and state licensure requirements.

An unannounced visit was conducted to investigate a complaint and annual survey at St. Joseph Villa Nursing Center on May 15, 2019-May 21, 2019, by representatives of the Department of Health and Human Services Division of Public Health.

The facility was found to be in compliance with complaint allegations related to falls, incident reports, injury prevention, visitor access, and call light response. Deficiencies were cited related to resident privacy, safe environment including water temperature and kitchen cleanliness, notification of hospital transfers, accuracy of Minimum Data Set, baseline care plans, care plan timing and revision, pain management, nursing staff competency, nurse aide in-service education, pharmacy services, medication labeling, dental services, infection prevention and control, and life safety code violations including means of egress, emergency lighting, hazardous area enclosure, cooking facilities, fire alarm system, sprinkler system, corridor doors, fire drills, gas equipment, and oxygen cylinder storage.

The complaint allegations investigated included failure to evaluate causal factors for falls, accuracy of incident reports, implementation of care planned interventions to prevent injuries, resident access to visitors, and prompt response to calls for assistance. The facility was found to be in compliance with these complaint allegations.

An unannounced visit was conducted to investigate a complaint alleging the facility failed to use appropriate interventions to prevent injuries.

The facility was found to be in compliance with relevant regulatory requirements, using appropriate interventions to prevent injuries. However, a deficiency was identified related to failure to recognize a reclining wheelchair as a potential restraint for one resident.

The complaint alleged the facility failed to use appropriate interventions to prevent injuries. The allegation was not substantiated as the facility used appropriate interventions, but a related deficiency was found regarding restraint identification.

An unannounced visit was conducted to investigate a complaint regarding the facility's standards of practice for initiating cardiopulmonary resuscitation (CPR) for a resident who had no advance directives.

The facility was found to be in compliance with relevant regulatory requirements, as residents reviewed had Advanced Directives for CPR and the facility followed standards of practice for initiating CPR.

The complaint alleged failure to follow standards of practice for initiating CPR for a resident without advance directives. The investigation found the allegation unsubstantiated.

An unannounced visit was conducted to investigate a complaint at St. Joseph Villa Nursing Center regarding allegations of failure to provide care to prevent wound development and failure to complete lab monitoring per care provider's orders.

The investigation found that the facility did provide care and services to prevent wound development and completed lab monitoring as ordered by care providers. The facility was in compliance with the regulatory requirements related to these allegations.

The complaint alleged failure to provide care to prevent wound development and failure to complete lab monitoring per care provider's orders. Both allegations were found to be unsubstantiated as the facility was in compliance.

An unannounced visit was conducted to investigate a complaint regarding failure to implement care planned fall interventions and failure to complete written investigations within five working days.

The facility was found to be in compliance with care planned fall interventions but failed to report an incident within the required 2-hour timeframe and failed to submit a completed written investigation within 5 working days due to a technical fax error. The facility was cited for the late reporting violation.

The complaint investigation was triggered by allegations that the facility failed to implement care planned fall interventions and failed to complete written investigations within five working days. The facility was found compliant with fall interventions but non-compliant with timely reporting and investigation submission. The allegation related to Resident 13 involved a significant injury (left femoral neck fracture) that was not reported to Adult Protective Services within 2 hours as required.

An unannounced visit was conducted to investigate a complaint at St. Joseph Villa Nursing Center regarding failure to identify change in condition and failure to implement interventions to prevent injuries.

The investigation found that the facility did identify changes in condition and implemented interventions to prevent injuries, resulting in no violations related to the allegations at the time of the investigation.

The complaint alleged failure to identify change in condition and failure to implement interventions to prevent injuries. Both allegations were found to be unsubstantiated.

An unannounced visit was conducted to investigate a complaint that the facility fails to identify change in condition.

The facility was found to identify change in condition through record reviews, quarterly and annual assessments, and routine visits by healthcare practitioners. The facility was found to be in compliance with regulatory requirements.

The complaint alleged the facility fails to identify change in condition. The investigation found the allegation to be unsubstantiated as the facility complied with regulatory requirements.

The facility's license was placed on probation for 90 days beginning March 14, 2018, due to violations of licensure regulations related to provision of care and treatment, specifically failure to implement and evaluate pain management programs.

The disciplinary action was based on violations of multiple licensure regulations including resident rights, charge nurse requirements, environmental services, administration, comprehensive care plans, medication errors, infection control, and others. The facility failed to implement and evaluate effective pain management programs as evidenced by the CMS-2567 report dated February 22, 2018.

An unannounced visit was conducted to investigate a complaint and annual survey at St. Joseph Villa Nursing Center from February 5, 2018 to February 12, 2018 by representatives of the Department of Health and Human Services Division of Public Health.

The facility was found to be in compliance with many regulatory requirements but had deficiencies including failure to implement timely fall interventions, failure to investigate bruising, failure to provide appropriate discharge notices, failure to maintain a safe and homelike environment, failure to report and investigate alleged abuse, failure to provide comprehensive care plans timely, failure to assist with personal care and grooming, failure to provide individualized activities, failure to prevent pressure ulcers, failure to provide adequate supervision to prevent accidents, failure to provide bowel incontinence evaluation and catheter care, failure to provide oral care for tube-fed resident, failure to manage pain effectively, failure to ensure pharmacy services prevent expired medication use, failure to maintain infection control practices, and multiple life safety code violations including blocked egress, improper door locking mechanisms, and inadequate fire door maintenance.

Complaint allegations included misappropriation, pest control, call system response, resident protection, plan of care adherence, staffing sufficiency, dignity and respect, fall interventions, wound care, discharge notices, and resident rights. Some allegations were substantiated including failure to implement fall interventions, failure to investigate bruising, failure to provide discharge notices, and failure to provide wound care as ordered.

The letter serves to amend the Health Insurance Benefits Agreement to update the certified bed locations within the facility as requested by the facility.

The agreement effective November 29, 2017, updates the certified bed locations to Rooms 100 through 111 and 300 through 303, maintaining a total of 32 Medicare certified beds.

An unannounced visit was conducted to investigate a complaint regarding inaccurate discharge information at St. Joseph Villa Nursing Center.

The facility failed to ensure discharge information was accurate but self-corrected by educating staff and taking disciplinary action. Follow-up reviews will be completed to ensure accuracy.

The complaint alleged that the facility failed to ensure discharge information was accurate. The investigation found this to be true but noted the facility self-corrected the issue.

An unannounced visit was conducted to investigate a complaint at St. Joseph Villa Nursing Center regarding allegations of neglect, failure to ensure prompt medical attention, and failure to provide care according to responsible parties' requests.

The facility was found to be in compliance with regulations on all allegations: residents were protected from neglect, received prompt medical attention, and care was provided according to responsible parties' requests.

The complaint alleged neglect, failure to ensure prompt medical attention, and failure to provide care according to responsible parties' requests. The investigation found the facility compliant with all allegations.

An unannounced visit was conducted to investigate a complaint at St. Joseph Villa Nursing Center regarding allegations of neglect, failure to ensure prompt medical attention, and failure to provide care according to responsible parties' requests.

The investigation found the facility was in compliance with regulations, protecting residents from neglect, ensuring prompt medical attention, and providing care according to responsible parties' requests.

The complaint alleged neglect, failure to ensure prompt medical attention, and failure to provide care according to responsible parties' requests. The facility was found to be in compliance with all these allegations.

The document is a Nursing Home Licensure Renewal Application and related disclosures for St. Joseph Villa Nursing Center, verifying licensure renewal and compliance with statutory requirements.

The documents confirm the facility meets statutory requirements for licensure renewal, including disclosures about ownership, specialized care unit services, bed count, and fire marshal occupancy certification.

An unannounced visit was conducted to investigate a complaint regarding the facility's failure to put interventions in place to prevent injuries.

The facility was found to have implemented interventions to prevent injuries, including evaluating falls for potential causal factors, care planning based on assessments, and knowledgeable staff implementing fall prevention interventions. The facility was found to be in compliance with related regulatory requirements.

The complaint alleged that the facility failed to put interventions in place to prevent injuries. The investigation found the facility in compliance with regulatory requirements regarding fall prevention.

An unannounced visit was conducted to investigate a complaint and annual survey at St. Joseph Villa Nursing Center on October 17-20, 2016, by representatives of the Department of Health and Human Services Division of Public Health.

The facility failed to ensure an effective housekeeping program, failed to evaluate and follow residents' bathing preferences, failed to provide adequate grooming assistance for one resident, failed to supervise smoking for one resident, failed to ensure drug regimens were free from unnecessary drugs for one resident, and failed to ensure proper labeling and storage of oxygen cylinders and outdated laboratory supplies. Life safety code deficiencies were also identified including issues with hazardous area doors, exit markings, fire doors, fire alarm visual notification, sprinkler coverage, combustible decorations, oxygen cylinder storage, emergency generator manual stop switch, and electrical receptacle GFCI protection.

The complaint investigation included allegations related to housekeeping, abuse, misappropriation, assistance for repositioning, prompt response to calls, and residents' ability to complain without retribution. The facility was found deficient in housekeeping but compliant in abuse, misappropriation, repositioning assistance, prompt response, and complaint protection.

An unannounced visit was conducted to investigate a complaint at St. Joseph Villa Nursing Center from August 8 to August 10, 2016, focusing on allegations that the facility failed to protect residents from injury and failed to notify appropriate parties of changes in condition.

The facility failed to protect residents from injury by not implementing interventions to prevent injuries and failed to notify physicians and emergency contacts of significant changes in residents' conditions, including suicidal statements. Additional deficiencies included inaccurate assessments, failure to revise care plans, inadequate infection control practices, and failure to implement fall prevention interventions.

The complaint investigation was triggered by allegations that the facility failed to protect residents from injury and failed to notify appropriate parties of changes in condition. The investigation included resident record reviews, observations, and interviews with residents, family members, and staff. The facility was found to have multiple deficiencies related to these allegations.

An unannounced visit was conducted to investigate a complaint regarding failure to follow the plan of care for transfers assistance, failure to investigate injuries of unknown origin, and failure to ensure residents are transferred safely to avoid injuries.

The facility was found compliant with the plan of care for transfers assistance but failed to investigate injuries of unknown origin for Residents 1 and 3, and failed to identify bruising for Resident 2. The facility was found out of compliance with Federal regulation F225 related to injury investigations.

The complaint alleged failure to follow the plan of care for transfers assistance, failure to investigate an injury of unknown origin, and failure to ensure residents are transferred safely. The facility was found compliant with transfer assistance but failed to investigate injuries of unknown origin and failed to identify bruising, resulting in noncompliance with Federal regulation F225.

The notice was issued to inform the facility of disciplinary action placing its license on probation for 90 days beginning May 18, 2016, due to violations related to failure to implement interventions to prevent falls.

The facility failed to implement interventions to prevent falls, as evidenced by violations cited in the CMS-2567 Report dated May 3, 2016, which is incorporated by reference in this notice.

An unannounced visit was conducted to investigate a complaint at St. Joseph Villa Nursing Center from April 13, 2016 to April 18, 2016, focusing on allegations related to resident-to-resident behaviors, misappropriation, staff training, injury prevention, abuse, investigation timeliness, and fall interventions.

The facility was found compliant with most allegations including interventions to prevent resident-to-resident behaviors, protection from misappropriation and abuse, staff training, and injury prevention. However, the facility failed to submit investigations within five working days for three residents and failed to implement fall interventions for one resident identified at risk for falls, constituting violations of federal and state requirements.

The complaint investigation was substantiated with findings that the facility failed to submit investigations within five working days for three residents (Residents 5, 8, and 13) and failed to implement fall interventions for Resident 15, who was identified as high risk for falls.

The document is a Nursing Home Licensure Renewal Application and related certification materials for St. Joseph Villa Nursing Center, verifying the renewal of the skilled nursing facility license.

The document confirms that St. Joseph Villa Nursing Center meets statutory requirements for licensure renewal as a skilled nursing facility with specialized care services including physical therapy, occupational therapy, speech therapy, and an Alzheimer's unit.

An unannounced visit was conducted to investigate a complaint and annual survey at St. Joseph Villa Nursing Center on July 8, 2015-July 15, 2015.

The facility failed to protect residents from abuse in two allegations, failed to report and investigate timely, and failed to implement interventions to protect residents during investigations. The facility was found in compliance with other allegations including protection from misappropriation, scabies, participation in religious events, isolation, grooming, injury investigations, staffing, discharge reasons, visitors, and range of motion care.

The complaint investigation revealed failure to protect residents from abuse, failure to report and investigate allegations timely, and failure to implement protective interventions during investigations.

An unannounced visit was conducted to investigate a complaint regarding the facility's failure to implement new fall interventions to prevent injuries and to ensure interventions are in place to prevent accidents.

The facility was found to have implemented new fall interventions and ensured interventions were in place to prevent accidents. Reviews of resident records, observations, and staff interviews confirmed compliance with relevant regulatory requirements.

The complaint alleged failure to implement new fall interventions and failure to ensure interventions to prevent accidents. The investigation found the facility in compliance with these allegations.

An unannounced visit was conducted to investigate multiple complaints at St. Joseph Villa Nursing Center, including allegations of misappropriation, failure to submit investigations timely, inadequate infection control, lack of informed consent for physician changes, missing practitioner's orders, insufficient staff training, failure to evaluate removal of safety bars, lack of resident communication access, failure to protect residents from abuse, and failure to prevent accidents.

The facility was found to be in compliance with most regulatory requirements, including protection from misappropriation, infection control, informed consent for physician changes, treatment per physician orders, staff training, evaluation of safety bars, resident communication access, protection from abuse, and accident prevention. However, the facility failed to submit one investigation report within the required timeframe, which was substantiated but did not result in a deficiency.

The complaint investigation included multiple allegations, with substantiation for the failure to submit an investigation report timely. Other allegations were found to be unsubstantiated or in compliance.

An unannounced visit was conducted to investigate a complaint regarding the facility's failure to ensure residents are supervised to prevent falls and to ensure interventions are in place to prevent accidents.

The facility ensured residents were supervised to prevent falls and interventions were in place to prevent accidents. However, a fall with significant injury for one resident was not reported or investigated and forwarded to the survey agency, constituting a violation of Federal requirement F225 and State regulation 175 NAC 12-006.02.

The complaint alleged the facility failed to ensure residents were supervised to prevent falls and failed to ensure interventions were in place to prevent accidents. The allegations were not substantiated except for the failure to report a fall with significant injury for one resident.

An unannounced visit was conducted to investigate a complaint and annual survey at St. Joseph Villa Nursing Center from June 2, 2014 to June 9, 2014.

The facility was found deficient in multiple areas including failure to provide dental care as directed, privacy violations during personal care, lack of resident bathing choice, incomplete care plans, failure to implement interventions for pressure ulcers and weight loss, inadequate food temperature control, and fire safety code violations including door latching, exit signage, smoke barrier penetrations, sprinkler system maintenance, and electrical safety.

The complaint alleged the facility failed to provide dental care as directed by practitioner. The complaint was substantiated as oral care was not provided to two residents in accordance with orders.

The document serves as a Notice of Disciplinary Action against St. Joseph Villa Nursing Center for failure to implement and evaluate a bowel management program for one resident, resulting in probation for 90 days starting May 2, 2014.

The facility was found in violation of licensure regulations related to urinary/bowel function due to failure to implement and evaluate a bowel management program for one resident. The probation requires submission of a Plan of Correction and periodic reports on residents identified as requiring bowel management.

An unannounced visit was conducted to investigate a complaint survey at St. Joseph Villa Nursing Center on April 7-8, 2014, triggered by allegations related to fall interventions, prevention of fecal impaction, and notification of family or responsible party of change in condition.

The facility was found compliant in changing fall interventions after residents were identified at risk for falls and notifying family or responsible party of change in condition. However, the facility failed to provide care and services to prevent fecal impaction and failed to notify the physician of a change in condition related to bowel complications for one resident, resulting in a violation of regulatory requirements.

The complaint alleged the facility failed to change fall interventions after residents were identified at risk for falls, failed to provide care and services to prevent fecal impaction, and failed to notify family or responsible party of change in condition. The investigation found the facility compliant with fall interventions and family notification but deficient in preventing fecal impaction and notifying the physician of a change in condition.

An unannounced visit was conducted to investigate a complaint at St. Joseph Villa Nursing Center on March 5-6, 2014, focusing on multiple allegations regarding resident care and facility operations.

The facility was found to be in compliance with all related regulatory requirements across multiple allegations, including personal item accountability, meeting residents' needs, grooming, food preferences, call system responsiveness, fall interventions, abuse prevention, staffing levels, and resident safety.

The investigation addressed numerous allegations including failure to account for personal items, failure to meet residents' needs, failure to ensure grooming, failure to meet food preferences, failure to answer call systems promptly, failure to serve food timely, failure to initiate interventions after resident incidents, failure to protect residents from injury, failure to change fall interventions, failure to follow care plans, failure to ensure grievance expression without retaliation, failure to prevent abuse, failure to prevent chemically impaired staff from providing care, failure to maintain staffing levels, and failure to protect residents from other residents' behaviors. All allegations were found to be unsubstantiated with the facility in compliance.

Routine inspection conducted to assess compliance with regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities.

The facility failed to administer medication in accordance with physician orders for one resident, resulting in a significant medication error. Additionally, the consultant pharmacist failed to identify a medication transcription error during a drug regimen review. The facility did not complete a medication error report for the incident.

The inspection was conducted to assess compliance with regulations governing licensure of skilled nursing facilities, focusing on accident hazards, supervision, and use of assistive devices.

The facility failed to operate mechanical full body lifts according to manufacturer instructions for 3 sampled residents, specifically not opening the legs of the lift during transfers and locking caster wheels improperly.

Annual inspection of St. Joseph Villa Nursing Center to assess compliance with federal and state regulations including facility management of personal funds, conveyance of personal funds upon death, housekeeping and maintenance services, care planning, ADL care, accident hazards, nutrition status, drug regimen, food safety, pharmaceutical services, and life safety code standards.

The facility was found deficient in multiple areas including failure to provide residents access to personal funds during nights and weekends, delayed conveyance of personal funds upon death, maintenance issues with doors and laminates, failure to update care plans after falls, call light accessibility, whirlpool water temperature safety, nutrition interventions, medication indications and monitoring, food safety practices, expired medications on carts, life safety code violations including obstructed doors, lack of latching devices, fire drill scheduling, use of portable heaters, flammable decorations, oxygen safety, electrical wiring issues, and improper placement of alcohol-based hand rub dispensers.

The inspection was conducted as a routine annual survey to assess compliance with state and federal regulations governing skilled nursing facilities.

The facility failed to update care plans for two residents to reflect current transfer interventions to prevent falls, and failed to provide adequate assessment and documentation of a surgical wound for one resident. These deficiencies indicate lapses in care planning and wound management.

Annual life safety code survey and comprehensive facility inspection to assess compliance with state and federal regulations.

The facility was found deficient in multiple areas including failure to notify legal representatives of self-harm statements, failure to report significant injuries and elopements, inadequate call light response times, failure to maintain facility environment and equipment, incomplete care plans, failure to monitor dialysis access sites, pressure ulcer prevention, accident hazard prevention, infection control, and multiple life safety code violations including fire barriers, smoke doors, emergency lighting, fire drills, sprinkler system maintenance, electrical safety, and oxygen safety.

The document serves as a renewal application for the nursing home license of St. Joseph Villa Nursing Center and includes related licensing and occupancy permits.

The documents certify that St. Joseph Villa Nursing Center meets statutory requirements for skilled nursing facility licensing, with a licensed capacity of 184 beds. It includes ownership information, bed count details, and special care unit disclosures.

The document serves as a renewal application for the nursing home license of St. Joseph Villa Nursing Center, including disclosure of ownership and control, certification of specialized care units, and related administrative information.

The documents confirm the facility's licensure renewal status, ownership structure, specialized care unit endorsement, and compliance with state requirements including fire marshal occupancy permit and bed count.

The documents serve to verify and renew the license for St. Joseph Villa Nursing Center, confirm ownership and control disclosures, and provide occupancy permit details including bed count and facility layout.

The documents confirm that St. Joseph Villa Nursing Center meets statutory requirements for skilled nursing facility licensure, has an occupancy permit for 184 beds, and includes an Alzheimer's Special Care Unit with specified staffing and care features.

The notice serves to inform St. Joseph Villa Nursing Center of disciplinary action placing their license on probation for 180 days starting July 4, 2014, due to violations of licensure regulations related to resident care.

The facility failed to implement interventions and evaluate causal factors to prevent and heal pressure ulcers and weight loss, resulting in disciplinary action and probation.

This Notice of Disciplinary Action was issued to St. Joseph Villa Nursing Center due to violations related to the provision of care and treatment, specifically the treatment of pain, and failure to implement and re-evaluate interventions to prevent resident pain.

The facility was found in violation of multiple licensure regulations including provision of care and treatment, charge nurse requirements, preliminary nursing care plan, urinary/bowel function, accidents, and infection control. The violations were evidenced by failure to implement and re-evaluate interventions to prevent resident pain.

The document serves as a renewal application for the nursing home license of St. Joseph Villa Nursing Center and includes related ownership disclosures and endorsements.

The documents certify the facility's license renewal, disclose ownership and control information, and provide details on the Alzheimer's Special Care Unit endorsement including staffing, care philosophy, and fees.

This document serves as a licensure renewal application for St. Joseph Villa Nursing Center, including ownership disclosures, occupancy permit, bed count, and Alzheimer's special care unit endorsement application.

The documents verify the facility's licensure renewal status, ownership and control disclosures, occupancy permit with maximum capacity of 184 beds, and detailed information about the Alzheimer's Special Care Unit including staffing, care philosophy, and fees.