Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St. Joseph's Villa, Inc. during CMS and state inspections, most recent first.
Surveyors found expired and unlabeled food items, improper storage of staff and resident food, and unclean refrigerators in the facility. Staff failed to perform proper hand hygiene between glove changes during food preparation, and there was no system for labeling or discarding food brought in by families. These issues had the potential to affect all residents consuming food from the kitchen.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Three residents experienced extended periods without documented bowel movements, and staff failed to administer PRN bowel medications as ordered or follow the facility's bowel protocol. Despite clear physician orders and established policies, no interventions were provided during these episodes, and care plans lacked appropriate constipation prevention measures. Staff and DON interviews confirmed the protocol was not followed and required actions were not taken.
A resident with multiple medical conditions and a history of repeated falls was not moved closer to the nurse's station as required by the care plan following a fall. Despite the intervention being documented, staff interviews and observations confirmed the resident remained in a room farthest from the nurse's station, and there was no documentation of refusal by the resident or family. This failure to implement the planned intervention resulted in a deficiency related to accident prevention and supervision.
A resident with chronic respiratory conditions did not receive oxygen therapy as ordered by the physician. Staff set the oxygen concentrator above the prescribed flow rate and failed to ensure the resident wore the nasal cannula, resulting in low oxygen saturation levels before intervention by a nurse.
Staff failed to properly disinfect blood glucose monitoring machines between resident uses, did not consistently perform hand hygiene when administering medications, and did not maintain oxygen equipment according to policy. An LPN was observed skipping required cleaning steps and hand hygiene, while a medication aide did not follow the manufacturer's recommended contact time for disinfectant wipes. A resident with chronic respiratory issues had an oxygen concentrator with a dirty filter and a nasal cannula that was placed on the floor and then used without cleaning.
A facility failed to follow a resident's full code status and CPR protocol when the resident was found unresponsive. Despite the resident's wishes for CPR, the LPN on duty did not initiate it, citing the resident's appearance as signs of clinical death. The agency nurse had not received adequate orientation on the facility's CPR policy, contributing to the deficiency.
The facility failed to report falls resulting in serious injuries to the state agency within the required time frame for two residents. One resident with multiple sclerosis and quadriplegia fell, resulting in a shoulder fracture, while another with dementia sustained a fractured clavicle. Additionally, the facility did not submit investigation reports within five working days for two residents, including one with Alzheimer's and Down Syndrome who suffered a facial laceration.
The facility failed to implement Enhanced Barrier Precautions for residents with catheters and wounds, and did not properly store or clean respiratory equipment. Observations showed catheter bags touching the floor and respiratory equipment improperly stored. Hand hygiene was not followed during wound and catheter care, with staff failing to perform hand hygiene between glove changes. The DON confirmed these deficiencies.
A resident with obstructive sleep apnea and other health conditions was observed to have a C-PAP machine in their room, and records showed its nightly use. However, the MDS did not reflect this treatment, as confirmed by the MDS coordinator, indicating a documentation deficiency.
A facility failed to conduct a Level II PASARR evaluation for a resident diagnosed with schizophrenia. The resident's Admission MDS indicated the presence of this serious mental illness, but the PASARR evaluation incorrectly stated no mental health diagnosis was known or suspected. This oversight was confirmed by the MDS Coordinator, who acknowledged the resident was not referred for the necessary evaluation.
A facility failed to obtain a physician order for a resident's CPAP use, despite the resident's diagnosis of obstructive sleep apnea and consistent use of the device since admission. The oversight was confirmed by the DON, highlighting a lapse in ensuring proper medical documentation.
Deficiencies in Food Storage, Labeling, and Hand Hygiene During Food Preparation
Penalty
Summary
Surveyors identified multiple deficiencies related to food safety and sanitation practices within the facility. During observations, expired food items such as thickened hot cocoa mix, honey thickener, chicken noodle soup, grape jelly, prune juice, and yogurt were found in various storage areas and refrigerators. Opened and undated food items, including chicken strips, breadcrumbs, pudding, pizza, chicken wings, apple sauce, and tomatoes, were also present. Staff food was stored alongside residents' food in unit refrigerators, and some items brought in by family members were not labeled or dated as required. Additionally, refrigerators were found to be unclean, with dried spills and sticky substances, and cleaning logs indicated that cleaning had not been performed for several days. During food preparation, staff failed to perform proper hand hygiene between glove changes. Specifically, a cook did not wash hands before donning new gloves after handling raw ingredients and after removing gloves, as confirmed by the Registered Dietitian. Interviews with the Dietary Manager and Registered Dietitian revealed there was no established system for labeling food brought in by families or for discarding old resident food. These deficiencies had the potential to affect all 52 residents who consumed food prepared in the facility's kitchen.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Monitor and Treat Constipation According to Bowel Protocol
Penalty
Summary
Surveyors identified that the facility failed to monitor bowel status and administer PRN medications to prevent constipation for three residents out of six sampled. For one resident with intact cognitive function and dependent for toileting, the care plan included a diagnosis of constipation but lacked interventions for prevention. Bowel monitoring forms showed multiple extended periods without documented bowel movements, some lasting up to 11 days, and medication administration records revealed that no bowel medications were given during these times, despite clear physician orders and a facility bowel protocol outlining specific interventions for consecutive days without a bowel movement. Interviews with staff and the DON confirmed that the bowel protocol was not followed and that no medications were administered as required. Another resident, admitted with multiple diagnoses including constipation, also experienced repeated periods with no documented bowel movements, sometimes for up to a week. Medication administration records for several months showed that no PRN bowel medications were given, even though physician orders and the facility's bowel protocol required specific interventions after two or more days without a bowel movement. The DON confirmed that the bowel management program was not followed for this resident and that the physician was not contacted when the resident exceeded five days without a bowel movement. A third resident, with severe cognitive impairment and total dependence on staff for toileting, was also found to have multiple periods with no documented bowel movements, some lasting up to ten days. The care plan did not address the risk for constipation or include interventions to prevent it. Despite having PRN bowel medications ordered, medication administration records showed that none were administered during the relevant periods. Staff interviews confirmed that the bowel protocol was not implemented for this resident, and the DON acknowledged that the required interventions were not provided.
Failure to Implement Fall Prevention Intervention for Resident with Repeated Falls
Penalty
Summary
The facility failed to implement a fall prevention intervention for a resident with a significant history of falls. According to the facility's Fall Prevention Program, when a resident experiences a fall, the care plan should be reviewed and a new intervention added before the end of the shift. After a fall on 10/24/2024, the intervention identified was to move the resident closer to the nurse's station and offer snacks between meals, as the fall was attributed to dizziness and hunger. However, the resident was not moved closer to the nurse's station, and there was no documentation that the resident or their family refused a room change. Observations confirmed that the resident continued to reside in a room farthest from the nurse's station, approximately 129 feet away, despite the care plan intervention. The resident involved had multiple medical diagnoses, including Paranoid Schizophrenia, Morbid Obesity, ADHD, Anxiety, and Depression, and was moderately cognitively impaired with a BIMS score of 9. The resident required substantial to maximal assistance with several activities of daily living and had a documented history of numerous falls over several months. Interviews with facility staff, including the Social Worker, MDS Coordinator, and Administrator, confirmed that the intervention to move the resident closer to the nurse's station was not implemented, and there was no clear reason documented for this inaction. The failure to carry out the planned intervention constituted a deficiency in ensuring the area was free from accident hazards and that adequate supervision was provided to prevent accidents.
Failure to Follow Physician's Oxygen Order and Monitor Resident's Oxygen Use
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for oxygen administration for a resident with chronic respiratory failure, hypoxemia, obstructive sleep apnea, and Williams syndrome. The resident's care plan required oxygen to be administered at 2 liters per minute (l/m) via nasal cannula as needed for oxygen saturations below 88%. However, observations revealed the oxygen concentrator was set at 3 l/m, exceeding the ordered flow rate. Additionally, the resident was observed multiple times without the nasal cannula in place, despite the oxygen concentrator running, and staff did not intervene to ensure the resident was receiving oxygen as ordered. Further review showed that the resident's oxygen saturation dropped to 83% while off oxygen, and only after this was noted did a nurse place the nasal cannula on the resident and adjust the flow rate. The failure to ensure the resident received oxygen at the prescribed rate and to monitor the resident's oxygen use as ordered resulted in the resident not receiving appropriate respiratory care according to physician orders and facility policy.
Infection Control Failures in Glucometer Disinfection, Hand Hygiene, and Oxygen Equipment Maintenance
Penalty
Summary
Staff failed to follow infection prevention and control protocols related to the use of blood glucose monitoring machines and hand hygiene. Observations revealed that an LPN did not sanitize the blood glucose monitoring machine before or after obtaining blood sugar readings for multiple residents. The same LPN also failed to perform hand hygiene after removing gloves and before leaving a resident's room, as well as before and after administering medications. These actions were in direct violation of the facility's policies, which require cleaning and disinfecting glucometers between each use and performing hand hygiene at appropriate times. Additionally, a medication aide was observed not following the manufacturer's instructions for disinfecting the glucometer. The aide used a Sani cloth germicidal wipe for only 8 seconds, despite the manufacturer's recommendation of a two-minute wet contact time. The aide was unaware of the required contact time, resulting in improper disinfection of the device between resident uses. There were also deficiencies in the management of oxygen equipment for a resident with chronic respiratory failure, hypoxemia, obstructive sleep apnea, and Williams syndrome. The resident's oxygen concentrator filter was observed to have a thick gray fuzzy coating, indicating it had not been cleaned as required. The nasal cannula was found on the floor and was not replaced or cleaned before being placed back on the resident. Staff walked by without addressing the resident's oxygen needs, and the resident was later found with low oxygen saturation. The filter was only cleaned after being pointed out, and the nasal cannula that had been on the floor was used without cleaning.
Failure to Follow CPR Protocol and Resident's Code Status
Penalty
Summary
The facility failed to adhere to Resident 1's wishes for Cardiopulmonary Resuscitation (CPR) and did not adequately train agency staff on code status and the facility's CPR policy and procedures. Resident 1, who was admitted with multiple severe health conditions including acute on chronic respiratory failure, congestive heart failure, and severe pulmonary hypertension, had designated full code status. Despite this, when the resident was found unresponsive, blue, and without a heartbeat, CPR was not initiated by the Licensed Practical Nurse (LPN) on duty. The LPN, identified as LPN-A, called 911 and was informed by the operator that the Sheriff would be sent first for a death investigation before an ambulance could be dispatched. Despite knowing the resident's full code status, the LPN did not initiate CPR, citing the resident's cold and blue appearance as signs of clinical death, which was in line with the facility's policy. However, this decision was made without following the proper protocol of initiating CPR in the absence of obvious signs of clinical death, as per the facility's policy. Interviews revealed that the agency nurse, LPN-D, did not receive adequate orientation regarding the facility's CPR policy or procedures for code situations. The facility's administration was unaware that the orientation competency form was not being completed for agency staff, which contributed to the failure to initiate CPR. The lack of proper training and communication regarding code status and CPR procedures led to the deficiency in following the resident's advance directives and the facility's own policies.
Removal Plan
- We identified other residents that are full codes.
- We updated the CPR policy and Communication of Code Status Policy.
- CPR Orientation document was implemented for orientation procedure for nursing agency.
- All agency prior to their shift will be oriented and educated on the CPR Orientation document.
- We completed the CPR orientation form and educated Night Charge Nurse and Day Charge Nurse via phone by the DON (Director of Nursing).
- All Agency nursing will be orientated by the DON.
- All current staff educated by DON.
- All staff prior to the next working shift will be educated by the DON.
- Code lists were updated and are placed in the narcotic books on the med carts, and on the clip board on the crash cart, and can be found in the chart on PCC (Point Click Care) by the DON.
- The DON will continue to keep the code lists updated with all new admissions and any change in DNR status with residents.
- All new hires will be educated through a PowerPoint on Relias on the following documents: CPR policy and Communication of Code Status policy, CPR Orientation document, and Resident Code Status.
- All New Agency staff will be educated on the following documents: CPR policy and Communication of Code Status policy, CPR Orientation document, and Resident Code Status prior to their shift.
- Administrator and/or DON will complete audits on new hires and agency staff.
Failure to Timely Report Falls and Submit Investigation Reports
Penalty
Summary
The facility failed to report incidents of falls resulting in serious bodily injury to the state agency within the required time frame for two residents. Resident 1, diagnosed with multiple sclerosis and quadriplegia, experienced a fall on September 3, 2024, resulting in a shoulder fracture. The incident was not reported to Adult Protective Services (APS) until later that day, and the investigation report was not submitted to the state agency until September 18, 2024. Similarly, Resident 4, who has dementia, fell on September 15, 2024, and sustained a fractured clavicle. This incident was not reported to APS until September 19, 2024, and there was no documentation of the fall in the progress notes until September 17, 2024. Additionally, the facility failed to submit written investigations within five working days for two residents. Resident 2, with Alzheimer's disease and Down Syndrome, fell on September 6, 2024, resulting in a facial laceration that required sutures. The investigation report for this incident was not sent to the state agency until September 18, 2024. Interviews with the Administrative Trainee confirmed these reporting delays and failures to meet the required timelines for submitting investigation reports.
Inadequate Infection Control and Equipment Storage
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents, including those with catheters and wounds. Observations revealed that catheter bags for Residents 41, 25, and 21 were hanging from bed frames with urine bags touching the floor, and there were no EBP supplies in their rooms. Similarly, Residents 13, 50, and 14 did not have EBP for wound care. The Director of Nursing (DON) confirmed the absence of EBP and stated that a policy had been approved but not yet implemented. The facility also failed to properly store and clean respiratory equipment for Residents 28 and 41. In Resident 28's room, a CPAP machine was observed with its mask and tubing improperly stored, while Resident 41's nebulizer equipment was left on a recliner without a barrier. The DON acknowledged that the equipment was not being cleaned and stored as required by the facility's policies. Additionally, hand hygiene practices were not followed during wound and catheter care for Residents 14 and 25. An LPN did not perform hand hygiene before and after wound care for Resident 14, and gloves were taken from a scrub pocket instead of a glove box. Similarly, a Medication Aide (MA) did not use EBP or perform hand hygiene between glove changes during catheter care for Resident 25. The DON confirmed that these practices did not meet the facility's expectations.
Inaccurate MDS Documentation for C-PAP Use
Penalty
Summary
The facility failed to accurately document the use of a C-PAP machine for a resident with multiple health conditions, including obstructive sleep apnea, on the Minimum Data Set (MDS). The resident, who was diagnosed with paranoid schizophrenia, chronic respiratory failure with hypercapnia, morbid obesity with alveolar hyperventilation, obesity, obstructive sleep apnea, and parkinsonism, was observed to have a C-PAP machine in their room. The machine was noted to be connected and present on two separate occasions. Despite the presence of the C-PAP machine and a medication administration record indicating its nightly use, the MDS for the resident did not reflect this treatment under Section O, which is designated for special treatments, procedures, and programs. An interview with the MDS coordinator confirmed that the C-PAP should have been marked on the MDS, indicating a lapse in accurately recording the resident's treatment plan.
Failure to Conduct Level II PASARR for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that the PASARR (Pre-Admission Screening and Resident Review) process was accurately completed for a resident with a mental disorder. Specifically, the facility did not conduct a Level II PASARR evaluation for a resident diagnosed with schizophrenia, a serious mental illness. The resident's Admission MDS, dated July 17, 2024, indicated the presence of this diagnosis. However, the current PASARR evaluation, dated July 1, 2024, incorrectly stated that no mental health diagnosis was known or suspected. This discrepancy was confirmed during an interview with the MDS Coordinator, who acknowledged that the resident was admitted with a mental illness diagnosis and was not referred for the necessary Level II PASARR evaluation to ensure the facility could meet the resident's needs.
Failure to Obtain Physician Order for CPAP Use
Penalty
Summary
The facility failed to obtain a physician order for the use of a continuous positive airway pressure (CPAP) machine for a resident diagnosed with obstructive sleep apnea. The resident, who was admitted to the facility and had a BIMS score of 14, indicating relatively high cognitive function, was observed using a CPAP with oxygen consistently since admission. Despite the resident's continuous use of the CPAP, confirmed by both the resident and their family member, the facility did not have a physician's order for the device. This was acknowledged by the Director of Nursing during an interview, confirming the oversight in obtaining the necessary medical order for the resident's CPAP use.
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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 David City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookestone Of David City | 0.8 mi | ★★★★★ | 0 | 0 |
| Emerald Nursing & Rehab Columbus | 18.3 mi | ★★★★★ | 30 | 0 |
| Brookestone Acres | 19 mi | ★★★★★ | 18 | 0 |
| Good Samaritan Society - Osceola | 22.6 mi | ★★★★★ | 0 | 0 |
| Ridgewood Rehabilitation & Care Center | 23.2 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.