St. Joseph Villa Nursing Center

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to implement intervention to prevent the potential for hot liquid burns on 2 (Residents 1 and 2) of 3 sampled residents. The facility census was 156.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.07(C) Based on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program identified and addressed concerns related to deficient practice identified on the survey and ensure correction for repeat deficient practice from previous surveys were maintained. This had the potential to affect all residents that resided in the facility. The facility census was 148.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) & 12-006.09(H)(iii)(3). Based on observation, interview and record review the facility failed to ensure fluid intakes and daily weights were monitored according to practitioner orders for Resident 128, failed to ensure an air mattress was functioning to promote healing of diabetic wounds for Resident 16, failed to follow up on requested lab work for recurrent urinary tract infections for Resident 47, failed to ensure weekly weights were completed for Resident 2 and failed to complete neurological assessments after an unwitnessed fall for Resident 71. The facility census was 148.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was maintained at a palatable temperature for food delivered to residents rooms. This had the potential to affect 40 residents who receive room trays. The facility staff identified a census of 148.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(D) Based on observation, interview, and record review, the facility staff failed to perform hand hygiene between residents while assisting 16 (Residents 43, 107, 145, 149, 2, 97, 70, 163, 82, 110, 66, 143, 37, 30, 142, and 87) of 27 sampled residents with eating in a manor to prevent cross contamination. The facility census was 148.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i)(5). Based on interview and record review the facility failed to inform the physician and resident representative of a change in Abnormal Involuntary Movements Scale (AIMS) score for 1 (Resident 7) of 5 sampled residents. The facility census was 148.

Inspectors wroteBased on record review and interview, the facility failed to communicate with the hospital and failed to provide transfer documentation during a hospital transfer for 2 (Residents 6 and 154) of 4 sampled residents. The facility staff identified a census of 148.

Inspectors wroteBased on record review and interview, the facility failed to ensure a new PASARR (Pre-admission Screening and Resident Review, a screening to determine the presence of a mental illness or intellectual disability) referral had been completed after a diagnosis of a mental disorder was identified for 1 (Resident 10) of 1 reviewed for PASRR. The facility census was 148.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist with or offer oral hygiene during the morning routine for 1 (Resident 17) of 3 sampled residents. The facility staff identified a census of 148.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(1). Based on observation, interview and record review the facility failed to ensure the proper functioning of an air mattress for 1 (Resident 123) of 1 residents sampled. The facility census was 148.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to complete quarterly bed assist devices assessments and regular preventive maintenance checks on 1 (Resident 5) of 1 sampled resident's bed assist device. The facility census was 148.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, interview, and record review, the facility failed to set 1 (Resident 47) of 3 sampled resident's oxygen flowrate to the prescribed settings. The facility census was 148.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B)(ii) Based on observation, record review, and interview, the facility failed to assess and identify situational stressors and triggers related to post-traumatic stress disorder on 1 (Resident 39) of 4 sampled residents. The facility census was 148.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(A)(vi). Based on record review and interview, the facility failed to identify drug irregularities related to antipsychotic medication and adverse symptom monitoring for Resident 7 and failed to ensure the physician provided rationale for the use of multiple hypertensive (high blood pressure) medications for Resident 6 of 6 residents sampled. The facility census was 148.

Inspectors wroteBased on record review and interview the facility failed to ensure there was a qualified Dietary Manager (DM) or qualified nutrition professional full-time, part-time, or on a consultant basis. This had the potential to affect all residents in the building. The facility staff identified a census of 148.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18BBased on observation, interview and record review the facility failed to perform hand hygiene between glove changes in a manor to prevent cross contamination during perineal care (the cleansing of the perineum-the area between the anus and genitals-to maintain hygiene, prevent infection, reduce odor, and promote skin health) on Resident 1, 17, and 47 and failed to clean the nebulizer mask and nebulizer medication chamber (a machine used to deliver aerosolized medications to the lungs) between uses to prevent potential contamination for Resident 160. A total sample of 3 residents were observed for perineal care and 4 residents were observed for nebulizer equipment. The facility staff identified a census of 148.

Inspectors wroteBased on record review and interview, the facility failed to report allegations of potential abuse within 2 hours involving 2 [Residents 2 and 3] of 7 sampled residents in accordance with federal requirements. The facility had a total census of 150 residents.

Inspectors wroteLicensure reference: 175 NAC 12-006.04(A)(iii)(2) Based on record review and interview, the facility failed to ensure a check of the APS/CPS [Adult Protective Service/Child Protective Service] registry had been completed for 1 [Nurse Aide D] of 5 sampled direct care staff. The facility had a total census of 150 residents.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observation, interview and record review the facility staff failed to ensure Enhanced Barrier Precautions (EBP - an infection control strategy that focuses on prevention the spread of multidrug-resistant organisms (MDRO) were followed when wound care was provided to 1 (Resident 2) of 3 residents sampled. The facility staff identified a census of 145.

Inspectors wroteLICENSE REFERENCE NUMBER NAC 12.006.09(I) Based on record review and interview; the facility staff failed to transfer 1 (Resident 9) of 1 residents in a manner to prevent injury. The facility staff identified a census 159.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(D)(i) Based on observation, interview, and record review, the facility staff failed to secure medications in 2 unlocked medication carts . This had the potential to affect 10 residents identified as self-mobile who resided on the 100 hall. An observation on 8/19/24 at 7:10 AM revealed the medication cart unlocked and un attended on the 100 hall. An interview on 8/19/24 at 7:12 AM with Registered Nurse (RN)-J confirmed the medication cart had been unlocked and unattended. An interview on 8/19/24 at 7:17 AM with MA (Medication Assistant)-K confirmed the medication cart should not have been left unlock and out of sight of MA-K. An observation on 8/21/24 at 6:12-6:18 AM revealed MA-N walked away from the medication cart leaving the medication cart unlocked and unsupervised on the 100 hall. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11 Based on observation, interview and record review the facility failed to follow the menu to meet the nutritional needs of residents that received pureed meals. This affected 7 (Residents 43, 54, 63, 78, 79, 125, and 129) observed of 13 residents the facility had identified as requiring a pureed meal. The facility census was 159.

Inspectors wroteLICENSE REFERENCE NUMBER 175 NAC 12-006.18 AND 12-006.19(C)(i) Based on observations, interviews and record reviews, the facility failed to gown during personal cares for residents on Enhanced Barrier Precautions (EBP, is a strategy used in nursing homes to reduce the spread of Multi-Drug Resistant Organisms (MDROs) to prevent cross-contamination for 5 residents (Residents 64, 29, 66,144, 149) of 31 residents on EBP,failed to ensure Resident 8's nasal cannula was kept off the floor and ensure the laundry aide kept clean laundry away from the staff members clothing to prevent cross contamination. The facility census was 159.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12.006.05(S) Based on observation, record review, and interview, the facility failed to ensure privacy for 1 (Resident 95) of 1 residents reviewed by posting information regarding the resident's diet on the outside of the resident's door. The facility identified a census of 159.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09(H)(iii) Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 78) of 2 sampled resident's compression stockings (special hose used to treat venous disorders) and Prevalon boots (pressure relieving heel protectors) were applied per the physician's orders. The facility census was 159.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09(H)(iv)(2) Based on record review and interview, the facility failed to evaluate and implement a toileting program for 1 resident (Resident 1) of 2 residents. The facility identified a census of 159.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on record review and interview, the facility failed to have an indication for antibiotic use for 2 (Resident 28 and 144) out of 2 sampled residents. The facility staff identified a census 159.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on interview and record review, the facility failed to prevent potential COVID-19 infection as evidenced by the failure to offer, provide education, and give 2 residents (Resident 15 and 25) of 5 residents reviewed, the opportunity to accept or decline updated COVID-19 vaccination for 2024-2025. The facility identified a census of 159.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on interviews, record review, and facility document and policy review, the facility failed to protect the residents' right to be free from sexual abuse by a resident. Specifically, the facility failed to ensure 2 (Resident #141 and Resident #142) of 4 residents reviewed for abuse who resided on the memory care unit (MCU) and were cognitively impaired were free from sexual abuse. The facility census was 147.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09C Based on interviews, record review, and facility document and policy review, the facility failed to develop a comprehensive care plan for 2 (Resident #141 and Resident #142) of 29 residents reviewed for care plan implementation. Specifically, the facility failed to develop a care plan to address Resident #141 and Resident #142's relationship and behaviors. The facility census was 147.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09D1C Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to provide services to residents who were unable to carry out activities of daily living (ADL) necessary to maintain good grooming and personal hygiene for 1 (Resident #48) of 6 sampled residents reviewed for assistance with ADL care. Specifically, Resident #48 had fingernails that were long with dirty substances underneath the nails and chin hairs approximately 1 inch in length. The facility census was 147.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observations, record review, interviews, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. During the medication pass observation, there were two medication errors out of 29 opportunities, resulting in a 6.9% medication error rate. This affected 2 (Resident #111 and Resident #79) of 4 residents observed receiving medication during the medication pass. The facility census was 147.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on record review, interview, and facility policy review, the facility failed to ensure 1 (Resident #1) of 1 resident who received insulin was free from significant medication errors. Specifically, the facility failed to ensure staff administered Resident #1's insulin as ordered by the physician. The facility census was 147.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.04A1 Based on interviews, record review, and facility document review, it was determined the facility failed to ensure professional staff's licenses were active for 1 (Licensed Practical Nurse [LPN] KK) of 27 nurses employed by the facility. The facility census was 147.