Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Joseph's Hillside Villa during CMS and state inspections, most recent first.
Restroom Exhaust Vents Not Functioning in Multiple Resident Rooms. The facility failed to ensure restroom exhaust vents were working in 7 of 9 sampled resident restrooms. Observations showed vents in multiple resident rooms were not drawing air, and the MD confirmed there were no regular testing logs because the vents were not tested routinely. The DON stated the intelligent building system did not alert staff that the exhaust vent system was not working.
The facility failed to complete Significant Change MDS assessments within the required 14-day timeframe for two residents after significant changes in condition. One resident enrolled in hospice and the SCSA remained in progress, while another resident had a hospital transfer after a fall with a T-12 compression fracture and later hospice enrollment; in both cases, the MDSC confirmed the assessments were not completed on time.
A facility failed to accurately complete the PASARR for a resident, indicating no signs of mental illness despite the resident having Delusional Disorder and Recurrent Depressive Disorder. The resident's medical records and hospital discharge orders confirmed these diagnoses and the use of psychotropic medications. Interviews with the DON and SSD revealed the facility did not verify the PASARR's accuracy, leading to an inaccurate screening that could affect admission decisions and service needs.
A facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident with pressure ulcers and multiple diagnoses, including diabetes and cognitive impairment. The care plan and physician orders lacked documentation of EBP, and a nurse was observed changing dressings without appropriate PPE. Interviews confirmed the absence of EBP implementation and policy.
Restroom Exhaust Vents Not Functioning in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that restroom exhaust ventilation systems were working in 7 of 9 sampled resident restrooms, including rooms 201, 209, 316, 318, 404, 414, and 409. The facility’s Physical Environment: Electrical Equipment policy dated 3/30/23 stated that all electrical and patient care equipment would be maintained in safe operating condition and that the Maintenance Director would maintain schedules for routine inspection and maintenance of mechanical, electrical, and patient care equipment. However, the facility’s Exhaust Fan Summary dated 07/09/2026 stated that all systems were functioning, while the undated Daily Inspections did not show that resident restroom exhaust vents were checked. During observations, Resident 8’s restroom exhaust vent was not drawing air, Resident 9’s restroom exhaust vent was not drawing air, and the Maintenance Director observed that the exhaust vents in rooms 201, 209, 316, 318, 404, 414, and 409 were not drawing air from the restrooms. The Maintenance Director stated there were no testing logs available because the vents were not tested regularly, and the DON confirmed the facility was an intelligent building and the system did not alert staff that the exhaust vent system was not working.
Failure to Complete Significant Change MDS Assessments Timely
Penalty
Summary
The facility failed to ensure Significant Change Minimum Data Set (MDS) assessments were completed within 14 days for 2 residents when significant changes in condition occurred. The facility’s MDS Completion policy stated that a Significant Change in Status Assessment (SCSA) would be completed within 14 days of identifying a status change that met RAI manual requirements, including a major decline or improvement in status or a hospice enrollment, discontinuation, or provider change. For one resident, the record showed hospice was initiated after the hospice provider agreed to admit the resident, and the MDS Coordinator confirmed the significant change determination date was the hospice start date; however, the Significant Change MDS was still in progress and had not been completed or signed by the MDS Coordinator by the time of review. For the second resident, the record showed a hospital transfer after a fall with a T-12 compression fracture, and later hospice enrollment; in both instances, the Significant Change MDS assessments were signed after the 14-day timeframe. The MDS Coordinator confirmed that the change of condition was identified on return from the hospital and that the hospice enrollment also required a Significant Change MDS, but neither assessment was completed within 14 days of identification of the change.
Inaccurate PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accurate completion of the Preadmission Screening and Resident Review (PASARR) for a resident, which is a federally mandated screening tool used to determine appropriate placement and services for individuals with mental illness, intellectual disabilities, or related disorders. The PASARR for the resident, dated February 27, 2025, incorrectly indicated that there were no signs of serious mental illness or intellectual disability, despite the resident having documented diagnoses of Delusional Disorder and Recurrent Depressive Disorder. This discrepancy was confirmed through a review of the resident's medical records and hospital discharge orders, which listed psychotropic medications prescribed for these conditions. Interviews with the Director of Nursing and the Social Services Director revealed that the facility did not verify the accuracy of the PASARR, leading to an inaccurate screening that failed to reflect the resident's mental health diagnoses. This oversight could have impacted the decision regarding the need for additional screening and the appropriateness of the resident's admission or required services. The facility's policy mandates that all applicants be screened for serious mental disorders and intellectual disabilities, and the Social Services Director is responsible for tracking each resident's PASARR status, which was not adhered to in this case.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident, which is an infection control intervention designed to reduce the transmission of multi-drug resistant organisms (MDROs). The resident, who had mild cognitive impairment and was diagnosed with diabetes, anxiety, high blood pressure, and hardening of the arteries, was dependent on assistance for daily activities and had pressure ulcers. The resident's care plan, last revised in August, did not document the implementation of EBP, and the physician orders active in September also lacked documentation of EBP. During an observation in September, a registered nurse was seen changing the resident's dressings without using the appropriate personal protective equipment (PPE) beyond gloves, and no EBP measures were evident in or outside the resident's room. Interviews with the registered nurse and the Director of Nursing confirmed that EBP had not been implemented for the resident, and the facility did not have an EBP policy in place.
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What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Haven | 7.9 mi | ★★★★★ | 4 | 0 |
| Oakland Heights | 12.7 mi | ★★★★★ | 0 | 0 |
| Wisner Care Center | 14.5 mi | ★★★★★ | 8 | 0 |
| Clarkson Community Care Center Inc | 23.3 mi | ★★★★★ | 2 | 0 |
| Accura Healthcare Of Tekamah | 25.8 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.