St Joseph's Hillside Villa

In the surveyor’s words

From the most serious findings on record at St Joseph's Hillside Villa, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Jul 9, 2026

  Based on observation, interview and record review, the facility failed to ensure that the restroom exhaust ventilation system (vents) was working in 7 (resident room numbers 201, 209, 316, 318, 404, 414, and 409) of 9 sampled resident's restrooms. The facility census was 52. Findings are:A record review of the facility's Physical Environment: Electrical Equipment: policy dated 3/30/23 revealed the facility would maintain all electrical, and patient care equipment in safe operating condition. The Maintenance Director (MD) would maintain schedules for routine inspection and maintenance of all mechanical, electrical, and patient care equipment. A record review of the facility's Exhaust Fan Summary dated 07/09/2026 revealed all the systems were functioning. […]

• No harm, potential for more than minimal, patternF756Feb 7, 2023

  Licensure Reference Number 175 NAC 12-006.12B5 Based on record review and interview; the facility failed to have documented evidence of the required monthly pharmacist reviews for Resident's 5,15,17, 28, 41, and 43. The sample size was 6 and the facility census was 51. Findings are: A. Review of the facility policy, Pharmacist Consultant Expectations dated 5/2018 revealed the following; -The facility promoted and supported systems for quality resident care. -Provided pharmaceutical services in an accurate and safe manner in collaboration with the pharmacy consultant, facility leadership, facility staff, practitioners, and the Medical Director to meet the individual needs of the residents. […]

• No harm, potential for more than minimal, patternF758Feb 7, 2023

  Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to have appropriate diagnoses for the use of antipsychotic medication for Resident's 5 and 15, failed to have required stop dates for as needed anti-anxiety medication for Resident's 5 and 41, and failed to monitor for potential adverse side effects of Resident 32's antipsychotic (used to treat psychotic disorders)medication. The sample size was 6 and the facility census was 51. Findings are: A. […]

• No harm, potential for more than minimal, patternF881Feb 7, 2023

  Licensure Reference Number 175 NAC 12-006.17A Based on record review and interview the facility failed to implement an antibiotic stewardship plan. The sample size was 19 and the facility census was 51. Findings are: Review of the facility policy Antibiotic Stewardship dated 05/2018 revealed the following; -The goal of the Antibiotic Stewardship Program (ASP) was to promote the appropriate use of antibiotics to maximize treatment outcomes and minimize unintended consequences of antibiotic therapy. The ASP aimed to improve antibiotic prescribing practices through the development and implementation of antibiotic use protocols and a system to monitor antibiotic use. […]

• No harm, potential for more than minimal, isolatedF637Jul 9, 2026

  Based on observation, interview, and review, the facility failed to ensure a Significant Change Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's plan of care) was completed within 14 days for 2 (Residents 9 and 22) of 2 sampled residents. The facility census was 52. Findings are: A record review of the facility's MDS Completion policy dated 10/15/2022 revealed a Significant Change in Status Assessment (SCSA) would be completed within 14 days of the identification of a status change that meets the requirements outlined in Chapter 2 of the Resident Assessment Instrument (RAI) manual. […]