Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Villa during CMS and state inspections, most recent first.
A resident with a history of cerebrovascular accident and other conditions was improperly transferred using a sit-to-stand device instead of a Hoyer lift, leading to a shoulder fracture. The resident, unable to bear weight, was transferred by a CNA who did not report the incident, resulting in delayed recognition of the injury. The facility's documentation was inaccurate, and the bruising was not reported to management promptly.
The facility did not employ a full-time qualified dietitian or nutrition professional to direct nutrition services. The Dietary Manager lacked the necessary certification and training, relying on a contracted RD present only part-time. The DM had not completed essential courses or obtained required certifications in food service safety and management.
The facility failed to maintain confidentiality and completeness of medical records for over half of the sampled residents. Residents' names were found in incorrect records, and some hospital visit records were missing. Orders for tests and medications were misattributed, and a resident's emergency room visit records were absent until requested by surveyors.
A resident with a history of cerebrovascular accident was found with bruising and swelling on the left shoulder, which was not reported to management until two days later. The resident was diagnosed with a fracture after being transferred using a sit-to-stand machine. The delay in reporting the injury violated the requirement to report such incidents immediately or within 24 hours.
A resident with a pressure ulcer did not receive necessary dressing changes for 12 days, despite having a care plan in place. The resident's medical records showed multiple missed dressing changes, and interviews with staff revealed issues with updating and following wound care orders. The deficiency was identified due to the lack of timely and consistent care.
A resident with multiple health conditions, including cognitive communication deficit, requested dental services due to missing teeth and chewing difficulties. Despite documentation in the MDS assessment, the request was not communicated to Social Services, resulting in a missed referral and lack of dental care.
Inadequate Supervision and Improper Transfer Method Result in Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices for a resident, leading to an accident. Resident 217, who had a history of cerebrovascular accident, right bundle branch block, heart failure, and major depressive disorder, was dependent on staff for transfers due to his inability to stand. Despite this, on a specific date, CNA 4 used a sit-to-stand device to transfer the resident, contrary to the care plan that required a Hoyer lift with two-person assistance. During the transfer, the resident was unable to bear weight, causing his arms to move upward, but the transfer was completed without immediate signs of pain. Subsequently, the resident was found to have a swollen and bruised left shoulder, which was later diagnosed as a fracture of the left humeral surgical neck. The facility's investigation revealed that the injury likely occurred during the improper transfer by CNA 4. The resident's condition, compounded by his non-verbal status due to the cerebrovascular accident, meant he could not communicate pain effectively, delaying the recognition of the injury. The facility's documentation and communication were also found lacking. The weekly skin assessment inaccurately reported no skin issues, despite bruising being observed earlier. Additionally, the bruising was not reported to management until two days after it was first noticed. This delay in reporting and the initial use of an inappropriate transfer method contributed to the harm experienced by the resident.
Removal Plan
- Audit all residents with current sit to stand transfers to ensure the current lift being used is appropriate for the resident status.
- Perform re-education 1:1 in huddles or over the phone regarding change of condition, bruising, range of motion, and which lift is appropriate for resident current condition.
- Complete audits with department heads on spot checking rooms to ensure staff members are using the appropriate lift with two-person transfer.
- Make unit managers aware of any changes with therapy evaluation with the lifts.
Deficiency in Nutrition Services Staffing
Penalty
Summary
The facility failed to employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. The Dietary Manager (DM) admitted during interviews that she had not completed the required certification to work as a dietary manager. The facility relied on a contracted Registered Dietitian (RD) who was present at the facility only on Mondays, Tuesdays, and Thursdays, and was otherwise available by phone. Additionally, the DM had not completed a course in food service safety and management, a Certified Dietary Manager course, a certified food service manager course, or obtained a nationally recognized certification or associate degree or higher in food service and safety.
Confidentiality and Completeness Issues in Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality and completeness of resident medical records for 52 out of 89 sampled residents. The survey revealed that residents' names were incorrectly included in other residents' medical records, compromising the confidentiality of sensitive information. Additionally, some residents' medical records from hospital visits were not incorporated into their electronic medical records at the facility, indicating a lack of thorough documentation and accessibility. Specific instances of this deficiency were identified through the review of medical orders dated across several months. For example, orders for various laboratory tests and medication adjustments were found in the electronic medical records of multiple residents, suggesting a mix-up of records. This included orders for blood tests, medication changes, and other medical instructions that were not correctly attributed to the respective residents, leading to potential confusion and errors in medical care. Furthermore, the case of a resident who returned from an emergency room visit with a fracture was highlighted. The records from this emergency room visit were missing from the resident's medical records at the facility, which was only discovered upon the surveyor's request. This incident underscores the facility's failure to ensure that all relevant medical information is accurately documented and readily accessible in the residents' records.
Delayed Reporting of Resident Injury
Penalty
Summary
The facility failed to report an alleged violation involving potential abuse or neglect within the required timeframe. A resident, who had a history of cerebrovascular accident and was non-verbal, was found with bruising and swelling on the left shoulder. This was initially observed by a CNA, but the bruising was not reported to management until two days later. The resident was subsequently diagnosed with a fracture of the left humeral surgical neck after being sent to the emergency room for evaluation. The investigation revealed that the injury likely occurred during a transfer using a sit-to-stand machine, where the resident was unable to bear weight. Despite the presence of bruising, the weekly skin assessment inaccurately documented no skin issues. The delay in reporting the bruising and the subsequent injury to management and the State Survey Agency constituted a failure to comply with the requirement to report such incidents immediately or within 24 hours, depending on the severity of the injury.
Failure to Provide Consistent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident with a pressure ulcer, as required by professional standards of practice. The resident, who had a history of multiple medical conditions including encephalopathy, bacteremia, and severe protein-calorie malnutrition, was admitted with a pressure ulcer in the sacral region. Despite having a cognitive status indicating no impairment, the resident did not receive dressing changes for 12 days, which is a significant lapse in care. The resident's medical records indicated that the wound was initially assessed as an unstageable pressure injury with full-thickness skin and tissue loss. A wound care plan was established, which included specific instructions for cleansing, applying skin prep, and dressing changes. However, the Treatment Administration Record (TAR) showed that there were multiple instances where the dressing changes were not documented, indicating that the care plan was not followed consistently. Interviews with facility staff, including the Unit Manager and Director of Nursing, revealed that there were issues with updating and following wound care orders. The Director of Nursing admitted that upon the resident's readmission, there were no physician orders for wound care, and orders were only received several days later. This lack of timely and consistent wound care contributed to the deficiency identified by the surveyors.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident, identified as Resident 38, who had requested to see a dentist. Resident 38, who was admitted with conditions including fibromyalgia, systemic lupus erythematosus, chronic pain syndrome, depression, generalized anxiety, and cognitive communication deficit, expressed difficulty in chewing due to several missing teeth. Despite a quarterly Minimum Data Set (MDS) assessment indicating issues with dentures and chewing difficulties, the resident's request for dental care was not addressed. Interviews revealed a breakdown in communication and procedure within the facility. A registered nurse stated that requests for dental appointments should be communicated to Social Services, who are responsible for setting up such appointments. However, the Social Services Director was unaware of the resident's request documented in the MDS progress note, indicating a failure in the communication process. This oversight resulted in the resident not receiving the necessary dental care, as the referral for a dental appointment was missed.
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Illustrative
What surveyors actually found near you
We read the 155 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Salt Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monument Healthcare South Salt Lake | 0.8 mi | ★★★★★ | 0 | 0 |
| Meadow Brook Rehabilitation And Nursing | 1.1 mi | ★★★★★ | 14 | 0 |
| Little Cottonwood Rehabilitation And Nursing | 1.8 mi | ★★★★★ | 5 | 0 |
| Millcreek Rehabilitation And Nursing | 2 mi | ★★★★★ | 3 | 0 |
| Maple Ridge Rehabilitation And Nursing | 2.2 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.