St Joseph's Manor

Based on observation and staff interview, it was determined that the facility failed to store food in a sanitary manner in the main kitchen, two of seven resident pantries (Green Valley and the Meadows), and one of seven resident dining service areas (Green Valley). Findings include:Observation during the tour of the main kitchen, the [NAME] Valley resident serving area, and the [NAME] Valley resident pantry on January 6, 2026, beginning at 10:15 a.m., revealed the following: In the main kitchen, the floor mixer was in use and had areas of peeled paint on the front and top of the motorhead above the mixing bowl. In the [NAME] Valley resident dining service area refrigerator, there were four cups of yogurt with a use-by date of January 2, 2026. In the [NAME] Valley resident pantry refrigerator there was a carton of milk with a use-by date of January 4, 2026, and one cup of yogurt with a use-by date of January 2, 2026.Observation of the Meadows resident pantry refrigerator on January 7, 2026, at 11:23 a.m., revealed one large carton of apple juice with a use-by date of December 10,…

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 clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for two of 36 sampled residents. (Residents 4 and 13)Findings include: Clinical record review revealed that Resident 4 had diagnoses that included fibromyalgia (widespread body pain and fatigue) and depression. Review of the MDS assessment dated [DATE], revealed that Sections P (Restraints and Alarms) incorrectly indicated that the resident used a restraint, but less than daily. There was no documentation in the clinical record that indicated Resident 4 used any type of restraint during the review period. Clinical record review revealed that Resident 13 had diagnoses that included peripheral vascular disease and chronic embolism. Review of the MDS assessment dated [DATE], revealed that Section N (Medications) incorrectly indicated that the resident was receiving an anticoagulant medication during the previous seven days. There was no documented evidence that…

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 clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide services to maintain adequate grooming and hygiene for three of 36 sampled residents. (Residents 2, 102, and 245)Findings include: Clinical record review revealed that Resident 2 had diagnoses that included muscle weakness, end stage renal disease, and depression. The Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 2 required maximum assistance with hygiene and self-care and had no cognitive impairment. Review of the care plan revealed that staff were to assist the resident with hygiene and self-care, including nail care on bath day and as necessary. On January 6, 2025, at 12:46 p.m., the resident was observed in his room. His nails were long and dirty. He stated that he preferred short clean nails and that staff had not offered to provide nail care recently. On January 8, 2026, at 11:50 a.m., the resident was observed in his wheelchair. His nails remained…

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 clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for three of 37 sampled residents. (Residents 5, 29 and 201)684Based on a clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for three of 37 sampled residents. (Residents 5, 29 and 201)Findings include: Clinical record review revealed that Resident 5 had diagnoses that included Alzheimer's Disease, hypertensive chronic kidney disease, and type II diabetes. A physician's order dated August 21, 2024, directed staff to administer a blood pressure medication (atenolol) one time a day. The physician ordered that staff not administer the medication if the resident's heart rate was less than 55 beats per minute. Review of Resident 5's Medication Administration Records (MAR) for October, November, and December of 2025, revealed that the staff administered atenolol once each in October and November, and twice in December when Resident's 5's heart rate was less than 55 beats per minute.Clinical…

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 clinical record review, facility documentation review, observation, and staff interview, it was determined the facility failed to implement safety interventions for one of eight sampled residents at risk for falls. (Resident 15)Findings include: Clinical record review revealed that Resident 15 had diagnoses that included abnormality of gait and mobility, muscle weakness, and difficulty in walking. The Minimum Data Set assessment dated [DATE], revealed that Resident 15 required staff assistance for bed mobility and transfers. Review of facility documentation dated September 10, 2025, revealed the resident was found on the floor after rolling out of bed, with a new intervention to place falls mats on both sides of the bed. Review of the care plan identified that the resident was at risk for falls related to gait dysfunction with an intervention that staff were to place fall mats on both sides of the bed to prevent injury. Observations on January 6, 2026, at 11:45 a.m. and 2:00 p.m., and January 7, 2026,…

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 policy review, clinical record review, and staff interview, it was determined that the facility failed to notify each resident's responsible party of a significant weight loss for two of eight sampled residents. (Residents CL1 and 3) Findings include: Review of the facility policy entitled, Weight Management Guidelines, dated January 6, 2025, revealed that nursing staff were to report unexplained significant weight changes to the family/responsible party. Clinical record review revealed that Resident CL1 had diagnoses that included Alzheimer's dementia and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was rarely understood. Review of the resident's weights revealed that on February 6, 2025, the resident weighed 178.6 pounds (lbs). On March 2, 2025, Resident CL1 weighed 167.8 lbs, which was confirmed with a reweigh on March 4, 2025. This reflected a six percent weight loss in one month. There was no documented evidence that 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 clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for two of eight sampled residents. (Residents 3 and 5) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included hypertension (high blood pressure). A physician's order dated March 12, 2025, directed staff to administer a medication (lisinopril) one time a day for hypertension. Staff was not to administer the medication if the resident's blood pressure (BP) was less than 110 over 65 millimeters of mercury (mm/Hg). Review of Resident 3's medication administration records (MARs) revealed that staff administered the medication one time in March 2025, and two times in April 2025, when the resident's BP was less than 110 over 65 mm/Hg. Clinical record review revealed that Resident 5 had diagnoses that included hypertension. On April 17, 2025, the physician ordered staff to administer a medicine (metoprolol tartrate) two times a day for hypertension. Staff was not to administer the medication if the resident's systolic blood…

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 policy, observations, and staff interview, it was determined that the facility failed to store and serve foods in a sanitary manner in the dietary department to prevent the potential for foodborne illness. Findings include: Review of the facility policy entitled Food Storage, last reviewed March 8, 2024, revealed that food was to be stored immediately after receipt and maintained in a manner to prevent damage, spoilage, infestation, or bacterial contamination. Observation during the initial kitchen tour on February 11, 2025, at 10:00 a.m., revealed the following: There was debris on the bottom of the stand up ice cream freezer. There were four bins of dry goods that included white rice, flour, thickened liquid product, sugar and brown rice. The scoops for the dry goods were stored inside the bins on top of the dry goods. There was a container of whipped cream in a refrigerator that was not labeled or dated. In the dry goods storage room at 10:06 a.m, there was a bag of cereal that had been opened and re-sealed, but was not labeled or dated. There was also…

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 the facility assessment and dietary policies and procedures, it was determined that the facility failed to implement the facility wide assessment to ensure that there was an inventory of resources. These resources included an adequate supply of sustenance, food and beverages, in the event of an emergency/disaster for residents and staff. Findings include: Review of the facility assessment dated [DATE], revealed that the facility was to maintain and manage a documented inventory of resources that may be needed in an emergency. There was a reference in the facility assessment to the facility emergency preparedness plan. Review of the current, referenced emergency preparedness plan revealed, the facility was to ensure that adequate sustenance needs for residents and staff were to be available during an emergency. In addition, review of the policy entitled Food and Nutrition Disaster Plan, last reviewed March 8, 2024, revealed that the purpose was to allow for advance planning in possible…

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 clinical record review and staff interview, it was determined that the facility failed to ensure that physicians' orders were implemented for three of 36 sampled residents. (Resident 73, 185, 446) Findings include: Clinical record review revealed that Resident 73 had diagnoses that included dementia and muscle weakness. The Minimum Data Set (MDS) assessment, dated January 10, 2024, indicated that the resident was cognitively impaired and required substantial assistance for toileting. A physician's order dated November 5, 2019, directed staff to administer 30 milliliters (ml) of a laxative (milk of magnesia) if the resident did not have a bowel movement in two days, and then an enema (Fleet's) the next day if the resident still had no bowel movement. A review of the documentation revealed that no bowel movements were recorded from January 17 through 22, and from January 24 through 30, 2024. According to the Medication Administration Record (MAR) there was no documented evidence that laxatives or enemas…

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.