ST JOSEPH VILLA UT DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
02/17/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
02/17/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
02/17/2010	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
02/17/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
02/17/2010	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
02/17/2010	properly constructed linen or trash chutes.	Isolated	Minimal harm or potential for actual harm
02/17/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
02/17/2010	no-smoking signs where oxygen is used.	Isolated	Minimal harm or potential for actual harm
02/17/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
02/11/2010	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Pattern	Minimal harm or potential for actual harm
02/11/2010	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
02/11/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
02/11/2010	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
02/11/2010	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
02/11/2010	post nurse staffing information.	Widespread	Potential for minimal harm
02/11/2010	Get rid of garbage properly.	Pattern	Potential for minimal harm
02/11/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
02/11/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
02/11/2010	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
02/11/2010	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
11/19/2008	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Potential for minimal harm
11/19/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
11/19/2008	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Isolated	Minimal harm or potential for actual harm
11/19/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
11/19/2008	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
11/19/2008	emergency lighting that can last at least 1 1/2 hours.	Pattern	Potential for minimal harm
11/19/2008	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
11/19/2008	record of quarterly fire drills for each shift under varying conditions.	Pattern	Potential for minimal harm
11/19/2008	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
11/19/2008	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
11/19/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
11/19/2008	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
11/19/2008	restrictions on the use of highly flammable materials.	Isolated	Minimal harm or potential for actual harm
11/19/2008	weekly inspections and monthly testing of generators.	Pattern	Potential for minimal harm
11/19/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
11/06/2008	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
11/06/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
11/06/2008	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
11/06/2008	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
11/06/2008	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
11/06/2008	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
11/06/2008	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
11/06/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
11/06/2008	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Pattern	Minimal harm or potential for actual harm
11/06/2008	Get rid of garbage properly.	Pattern	Potential for minimal harm
11/06/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
09/05/2007	a two-hour-resistant firewall in common walls.	Isolated	Minimal harm or potential for actual harm
09/05/2007	fire-resistant interior walls.	Pattern	Potential for minimal harm
09/05/2007	fire-resistant room wall surfaces.	Pattern	Potential for minimal harm
09/05/2007	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
09/05/2007	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Isolated	Minimal harm or potential for actual harm
09/05/2007	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
09/05/2007	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
09/05/2007	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
09/05/2007	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
09/05/2007	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
09/05/2007	properly constructed linen or trash chutes.	Isolated	Minimal harm or potential for actual harm
09/05/2007	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
09/05/2007	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
08/16/2007	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Potential for minimal harm
08/16/2007	Properly mark drugs and other similar products.	Pattern	Potential for minimal harm
08/16/2007	Give or get lab tests to meet the needs of residents.	Pattern	Potential for minimal harm
08/16/2007	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm

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Where does this data come from?

The data on this website describes nursing home characteristics, quality measures, inspection results, and nursing staff information.

The data come from 2 sources:

1. Centers for Medicare & Medicaid Services (CMS) have an Online Survey, Certification, and Reporting (OSCAR) database - Includes the nursing home characteristics and health deficiencies issued during the three most recent state inspections and recent complaint investigations.

   The survey inspection results are collected by the state survey agencies, who perform onsite visits to nursing homes . The inspections occur at least once during a 15-month period, or any time in between as a result of a complaint received by the state. The inspections ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. Complaints may be reported and inspected during the year (outside of the 9-15 month survey cycle). Inspections about a complaint that result in the citation of a health deficiency are reported to CMS and included in this website. Sometimes the inspection finds a problem that the nursing home identified and corrected before the inspection occurred. The fact and the nature of these prior problems (deficiencies) may be included in this website.

   The information on the nursing homes' characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change.

2. National database known as the Minimum Data Set (MDS) Repository

   The data for the quality measures come from the MDS Repository. The MDS is collected on regular intervals for every resident in a Medicare or Medicaid certified nursing home. Information is collected on the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident.

   Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission.

   All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. Every attempt is made to assure the accuracy and timeliness of this information. However, this information changes frequently as residents are discharged and admitted, or resident conditions change. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman's office, the State Survey Agency, or other sources.

   Some MDS items used to calculate the quality measures consider the resident's condition during previous days prior to the assessment date. The following table provides these "observation" or "look back" time frames.

Signs of Nursing Home Abuse:

• Unexplained injuries or bruises
• Over or under medication
• Visible cuts, bruises, or welts
• Rapid weight loss or weight gain
• Dehydration, malnutrition, and bedsores
• Unsanitary living conditions
• Infections
• Broken bones
• Sudden death