St. Joseph's Villa, Inc.

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Oct 24, 2024

  Licensure 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. Findings are: A record of the facility's undated Cardiopulmonary Resuscitation policy revealed it was the policy of this facility to adhere to the residents' rights to formulate (create) advanced directives (a resident's medical care choice). […]

• No harm, potential for more than minimal, widespreadF812Aug 12, 2025

  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… […]

• No harm, potential for more than minimal, widespreadF812Oct 5, 2023

  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… […]

• No harm, potential for more than minimal, widespreadF812Aug 4, 2022

  LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, record review and interview, the facility staff failed to wear gloves when handling food to prevent the potential for food borne illness. This had the potential to affect 40 residents that eat from the kitchen. The facility staff identified a census of 40. The findings are: On 08/02/22 at 09:00 AM observation of Cook A and Interim Dietary Manager B during preparation for noon meal. Cook A obtained the ham from the refrigerator and removed the ham from the package. Cook A did not don gloves when touching the ham. Cook A then took the ham to the cutting board. Cook A cut the ham in half and placed half of the ham on the slicer and sliced a piece of ham into bare hands. […]

• No harm, potential for more than minimal, widespreadF812Mar 30, 2021

  LICENSURE REFERENCE NUMBER: 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure food was stored in sanitary conditions and hairnets fully covered the staff's hair to prevent food borne illnesses. The sample size was 13. The facility identified a census of 51. FINDINGS ARE: 03/24/31 at 09:00 AM aAn observation of a stand up freezer in the back storage room revealed it had contained meat throughout the freezer shelves and in the door. The freezer had large amounts of ice and frost preventing the freezer from closing without being locked shut. The observation revealed a dark colored substance to be on packages kept in the door. […]