St. Joseph's Nursing Home

Based on observation and interviews with facility staff, it was determined that the facility failed to manage expired food items. This deficiency was observed in the facility's kitchen during the recertification survey.The findings include:On 1/21/26 at 7:45 AM, the surveyor conducted an initial tour of the kitchen with Staff #24 (Cook). The facility's refrigerator contained opened food items with marked expiration dates that had passed. The surveyor noted the following expired items:-One opened bag of bagels (5 remaining) with an expiration date of 9/13/25.-One bag of raisin cinnamon bread with an expiration date of 12/03/25.-One bag of pumpernickel bread (20% remaining) with an expiration date of 11/28/25.-One bag of white bread with an expiration date of 1/13/26.-One bag of Hawaiian bread with an expiration date of 12/18/25.During a subsequent observation of the basement walk-in freezer at 8:00 AM on 1/21/26, the surveyor identified two foil-wrapped packs of ribs dated 11/22/25 and two 5-pound packs of low chicken dated 6/28/25. Staff #24 stated, Those items were for the sisters;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of pertinent documentation and interviews with facility staff, it was determined that the facility failed to have a system in place to ensure that the Resident Council was provided with responses, actions, and rationale taken regarding their concerns and to demonstrate the facility's response and rationale for such concerns. The Findings include: The Resident Council is a group of residents that meets regularly on the behalf of all residents in the facility to discuss concerns about facility policies and procedures affecting residents' care, treatment, and quality of life. Facility staff are required to consider resident and family group views and act upon grievances and recommendations. This may include developing or changing policies affecting resident care and life. Facility staff should discuss their decisions with the residents and/or family group and document their response and rationale in writing. The facility must be able to demonstrate their response and rationale. On 1/22/26 at 9:23 AM in an interview with the Director of Nursing (DON) she provided 1 sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of medical records and interview with facility staff, it was determined that the facility failed to notify the provider of blood in a resident's stool and urine and weakness leading to the resident needing to be fed their meals. This was evident for 1 (Resident #5) of 16 residents reviewed during the facility's recertification survey.The findings include:On 1/22/26 at 10:54 AM review of Resident #5's medical record revealed:-12/14/2025 6:43 AM Resident was assisted with toileting this morning. He/she was observed by GNA (Geriatric Nursing Assistant) to be straining, and he/she had some BM (bowel movement) mixed with a moderate amount of blood in the toilet.-12/14/2025 11:42 AM Around 7:30 AM private aide reported that resident had a moderate amount of blood on his/her depends, also resident, also blood was observed in the toilet after bowel movement.-12/14/2025 11:56 AM Before lunch nurse aid reported that resident needs more help with transferring (is weaker) and probably he/she will need to use mechanical lift (next time when toileting).-12/14/2025 6:58 PM Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of medical records and interviews with facility staff, it was determined that the facility failed to notify the physician regarding the status of a resident's indwelling Foley catheter. Specifically, staff failed to obtain physician orders for the replacement of dislodged catheters and failed to document these re-insertions in the medical record. This evident one resident (Resident #7) of one resident reviewed for urinary catheter care during this recertification survey.The findings include:A Foley catheter is an indwelling urinary catheter (IDC) that drains urine from the bladder into a collection bag.During a review of Resident #7's medical records from November 2025 to January 2026 on 1/22/26 at 1:08 PM, it revealed that progress notes indicated the catheter was found dislodged or came out on six separate occasions: 11/13/25, 11/20/25, 11/26/25, 12/04/25, 12/16/25, and 1/15/26. While notes indicated the catheter was re-inserted each time, there was no evidence that the physician was notified or that an order was obtained for re-insertion.Further review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews with facility staff and review of medical records and facility policy, it was determined that the facility failed to address pharmacy recommendations in a timely manner. This was evident for 2 (Resident #2 and Resident #11) of 5 residents reviewed for unnecessary medications during the facility's recertification survey. The findings include: The Medication Regimen Review (MRR) is a review of the medication regimen (plan) of each resident with the goal of promoting positive outcomes and minimizing adverse (negative) consequences and potential risks associated with medications. The MRR must be completed at least once a month by a licensed pharmacist and includes a review of the medical record to identify, report, and resolve medication-related problems, errors, and/or other irregularities. Irregularity refers to use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and/or that impedes or interferes with achieving the intended outcomes. An irregularity also includes, but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records and interviews with facility staff, it was determined that the facility failed to ensure medications were ordered with an adequate indication for use. This was evident for 1 (Resident #8) out of 5 residents reviewed for unnecessary medications during the facility's recertification survey.The findings include: Adequate Indication for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals, and after any safer treatments have been deemed clinically contraindicated.On 1/23/26 at 10:54 AM review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Further review revealed the resident was ordered:-Candesartan Cilexetil Oral Tablet 16 MG (milligrams) Give 1 tablet by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility records and interview with facility staff, it was determined the facility staff failed to ensure the required committee members consistently attended monthly Quality Assurance and Performance Improvement (QAPI) meetings.The findings include:On 1/28/26 at 1:09 PM review of the facility's QAPI monthly attendance records for 1/2025 to 12/2025 revealed the following:-The Medical Director failed to attend 5 of 12 meetings (May 2025, August 2025, September 2025, November 2025, December 2025).-The Nursing Home Administrator failed to attend 1 of 12 meetings (May 2025).On 1/28/26 at 1:36 PM in an interview with the Infection Preventionist/Staff Educator/QAPI Secretary (IP/SE/QAPIS #1) when asked how long she had participated in QAPI meetings, she stated she had been in the QAPI Secretary role for about 2 years. During the interview the 2025 QAPI attendance sheets were reviewed by IP/SE/QAPIS #1, and she reviewed, verified and confirmed the surveyor's findings. The surveyor shared this was a concern and she acknowledged understanding of the concern.

Based on observation, interview, and medical record review, it was determined that the facility failed to ensure maintaining an effective infection control program by failing to order contact precautions in a timely manner. This deficiency was identified for one resident (Resident #19) out of three reviewed for infection control during the annual recertification survey.The findings include:During the tour of the facility on 1/21/26 at 10:18 AM, the surveyor observed the contact precaution signage posted on the wall of Resident #19's room entrance.On 1/22/26 at 10:38 AM, the surveyor reviewed the records of three randomly residents currently receiving antibiotics. The review revealed that Resident #19 was diagnosed with Shingles (Herpes Zoster) by the attending provider on 1/19/26. Shingles is a painful, blistering rash caused by the reactivation of the varicella-zoster virus; per the Centers for Disease Control and Prevention (CDC), contact precautions are required to prevent the spread of the virus. However, no order for contact precautions was placed for Resident #19 until…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record reviews and staff interviews, it was determined that the facility failed to ensure that an employee's COVID-19 vaccination status was monitored and documented. This finding was evident for one of five staff members (Staff #17) whose immunization records were reviewed during the recertification survey.The findings include:The COVID-19 vaccine is intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease.On 1/22/26 at 11:38 AM, the surveyor reviewed the health files of five randomly selected employees. The review revealed that Staff #17 (Dietary Aide), who was hired in October 2024, lacked documentation to support their COVID-19 vaccination status.During an interview on 1/22/26 at 1:45 PM, the Infection Preventionist (IP #1) explained that upon hire, the facility collects copies of vaccination records and reviews the immunization status of all new employees. She stated that these records should include Flu, MMR, Hepatitis B, Tdap, Varicella, Tuberculosis (TB), and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interview, it was determined that the facility failed to store foods in a manner that protects them from contamination and in a manner to prevent spoilage. This was evident during the initial kitchen tour. The findings include: On 10/07/24 at 8:35 AM, an initial kitchen tour was conducted with Staff #1. An observation was made in the large walk-in refrigerator of the kitchen. A box of 6 yogurts with expiration date of 9/25/2024 were present. An open and undated package of bacon was seen sitting on an open rack above open containers of produce. These findings were verified by Staff #1. After surveyor intervention, Staff #1 discarded the box of 6 expired yogurts and the open and undated package of bacon. On 10/09/24 at 9:18 AM, an interview was conducted with the Certified Dietary Manager (Staff #8). When asked who handles the storage of perishable foods in the refrigerator, Staff #8 stated that she handles all the storing of the food products in the kitchen. When asked what their expectation was for how to check for product's expiration dates, Staff #8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review and staff interview it was determined the facility failed to ensure that a staff member did not make negative remarks about Residents #23 and #32 in front of them. This was evident for 2 of 5 residents present in the Day Room when the remarks were made. The findings include: On 10/22/19 at 12:05 PM, 5 residents were observed sitting in the Day Room. Two residents were sitting at tables being fed by Geriatric Nursing Aides (GNA)s #2 and #3. GNA #1 was standing in the middle of the room next to a resident but with her back to the surveyor. She was overheard saying, [He/she] has spit at me 3 times and I'm not going to feed [him/her] anymore. A tray on the table next to this resident had the name of Resident #32 on it. The surveyor then left the room to make observations in the main dining room. At 12:25 PM on 10/22/19 when the surveyor returned to the day room, GNA 3# was sitting at a table feeding a resident and GNAs #1 and #2 were sitting together at a different table and each feeding a resident. GNA #1 had her back to the surveyor and was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.