St. Joseph's Villa, Inc.

Inspectors wroteLicensure 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. [...]

Inspectors wroteLicensure 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. [...]

Inspectors wroteLicense 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09 Based on interview, and record review, the facility failed to ensure Resident 1's wishes were followed for Cardiopulmonary Resuscitation (CPR) and train agency staff on code status and the facility's CPR policy and procedures. The facility census was 44. The facility Administrator was notified on [DATE] at 6:04 PM of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteBased 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.

Inspectors wroteLicensure 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. [...]

Inspectors wroteLicensure 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.

Inspectors wroteLICENSURE 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.