Above average — CMS composite of the measures below.
The next survey window likely opens 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 Manor Health Care Inc during CMS and state inspections, most recent first.
A resident with ESRD and dialysis dependence had a physician order for midodrine 10 mg on dialysis days, to be held if SBP was above 130. Review of the MAR showed the medication was administered multiple times despite SBP readings above the ordered parameter, and nursing staff and the DON acknowledged the hold parameter should have been followed.
Failure to Follow Contact Precautions and Hand Hygiene: Staff entered a resident’s room while the resident was on Contact Precautions for VRE in the urine and repeatedly failed to follow required PPE and hand hygiene practices. CNAs and a nurse were observed entering and exiting the room without gowns, gloves, or hand hygiene, moving equipment into another resident’s room without cleaning it, touching another resident after leaving the room, and going to the clean linen cart after contact. Interviews showed staff had inconsistent understanding of the precautions in place and the required PPE.
Delayed Review of Urine C&S Result Led to Continued Inappropriate Antibiotic: A resident with COPD, CAD, AFib, and moderate cognitive deficits had a critical urine C&S showing Klebsiella pneumoniae, but the result was not communicated to the NP in a timely manner. The resident continued receiving Macrobid for several doses before the antibiotic was changed to ertapenem after the sensitivities were finally reviewed.
Unlabeled medications were found stored in a medication cart on an Applewood Unit cart. An LPN had prepared a resident’s morning meds, including a controlled substance, and left seven loose pills in an uncovered plastic cup in the cart drawer because the resident was at activities and had not returned. The DON stated the meds should not have been stored in an unlabeled cup and should have been discarded per procedure.
The facility failed to maintain food safety and sanitation standards, with observations of mouse droppings, debris, and expired food items in the kitchen, dining areas, and kitchenettes. The Food Service Manager acknowledged the issues, including the presence of mice and the need for proper cleaning and food labeling.
The facility failed to maintain an effective infection prevention and control program, particularly in managing COVID-19. The Infection Preventionist did not document contact tracing or verify staff testing compliance, and was unaware of updated guidelines. Additionally, the facility's infection surveillance system only tracked residents prescribed antibiotics, missing other potential infections. The Director of Nursing expected comprehensive investigations and tracking, but these were not implemented.
A resident with multiple medical conditions returned to a facility with a Foley catheter, which was not assessed for removal as per facility policy. Despite family requests and previous non-use of a catheter, the facility did not conduct a voiding trial or schedule a urology appointment. The resident experienced complications, and the facility's records showed no evidence of further assessment or specialist follow-up, leading to a deficiency.
Failure to Follow Midodrine Hold Parameters
Penalty
Summary
The facility failed to ensure care was provided in accordance with professional standards of practice when it did not follow the physician’s order for Resident #5’s midodrine. Resident #5 was admitted in October 2021 with diagnoses including ESRD and dependence on dialysis, and the MDS dated 10/7/25 indicated the resident received dialysis. The physician’s order directed midodrine 10 mg by mouth on Mondays, Wednesdays, and Fridays, with the medication to be held if systolic blood pressure (SBP) was above 130. Review of the October, November, and December 2025 MARs showed midodrine was administered on multiple occasions when the resident’s documented SBP exceeded the ordered parameter. In October 2025, this occurred on 11 occasions; in November 2025, on 7 occasions; and in December 2025, on 4 occasions. During interviews, Nurse #5, Nurse #2, the Unit Manager, and the DON all acknowledged the order parameter and stated the medication should not have been given when SBP was above 130, and the DON stated there was no evidence in the record showing the medication was not administered due to ordered parameters on those dates.
Failure to Follow Contact Precautions and Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. The facility’s Transmission-Based Precautions policy, last revised March 2025, stated that Contact Precautions require isolation gowns and gloves and are intended to prevent transmission of infections spread by direct or indirect contact. The policy also identified VRE as a microorganism requiring Contact Precautions. Resident #107 was admitted in May 2025 with diagnoses including UTI and was identified as being on Contact Precautions for VRE in the urine, while also having an EBP sign posted outside the room. On 12/8/25, the surveyor observed two CNAs enter Resident #107’s room, perform hand hygiene, don gloves, and use a mechanical lift to assist the resident back to bed. After leaving the room, one CNA removed gloves and took the mechanical lift into another resident’s room without performing hand hygiene or wiping down the lift, and the other CNA removed gloves but did not perform hand hygiene. On 12/9/25, the surveyor observed a CNA in the resident’s room without gloves or a gown and then leaving without hand hygiene. Later that day, a nurse entered the room and moved the resident’s bed without gloves or gown, exited without hand hygiene, and then touched another resident. The surveyor also observed the same CNA enter and exit the room multiple times without hand hygiene or PPE and go directly to the clean linen cart. On 12/10/25, the surveyor observed a CNA bring a breakfast tray into the resident’s room without PPE and then leave without hand hygiene. Later that morning, another CNA donned gloves to enter the room but did not perform hand hygiene first and did not wear a gown. Interviews confirmed staff understood the resident was on Contact Precautions for VRE in the urine, but one CNA stated only gloves were needed except during brief changes, another CNA said the resident was not on precautions, and the nurse stated the resident required Contact Precautions but she did not don PPE because she had only moved the bed. The Infection Perfectionist and DON stated staff should follow the more stringent precautions and wear appropriate PPE, with hand hygiene and gown and glove use when entering and exiting the room, and equipment should be wiped down when moved between resident rooms.
Delayed Review of Urine C&S Result Led to Continued Inappropriate Antibiotic
Penalty
Summary
The facility failed to ensure the physician or nurse practitioner was notified in a timely manner of a critical urinalysis culture and sensitivity report for one resident. Resident #69, who was admitted with diagnoses including severe COPD requiring oxygen, coronary artery disease, and atrial fibrillation, had a BIMS score of 12 out of 15, indicating moderate cognitive deficits. A urine sample was obtained for repeat urinalysis and C&S after the first sample was not picked up in time. The final culture report, dated 11/27/25, was positive for Klebsiella pneumoniae greater than 100,000 cfu/ml, but the report was first accessed by the facility on 12/1/25. During that delay, Resident #69 received Macrobid 100 mg twice daily for a positive UTI, with doses given on 11/28, 11/29, 11/30, and 12/1 before it was discontinued. The lab report was faxed to the facility on 11/27/25, but there was no written notation showing it had been read, and staff stated the C&S should have been reported to the on-call physician or NP when received. When the NP reviewed the result on 12/1/25, the antibiotic was changed from Macrobid to ertapenem because the sensitivities showed Klebsiella was more sensitive to ertapenem.
Unlabeled Medications Stored in Medication Cart
Penalty
Summary
The facility failed to ensure medications were stored and labeled in accordance with currently accepted professional standards. During observation and interview on 12/10/25 at 11:30 A.M., the surveyor and Nurse #3 reviewed the medication cart on the Applewood Unit and found one small, clear plastic medication cup in the top drawer that was uncovered, not labeled, and contained seven loose pills. Nurse #3 stated the cup contained medications for Resident #76 and explained she had prepared the morning medications, then kept them in the top drawer because the resident was attending activities and had not returned. Nurse #3 said she had not discarded the medications because there was a controlled substance in the cup, and she identified that the standard practice was to discard medications if the resident was not available. Review of Resident #76’s MAR showed scheduled 9:00 A.M. medications of aspirin 81 mg, losartan potassium 50 mg, metformin HCl ER 500 mg two tablets, metoprolol succinate ER 25 mg, multivitamin, and pregabalin 100 mg, which was identified as a controlled substance. During interview on 12/11/25 at 11:57 A.M., the DON stated the nurse should not store medications in an unlabeled medication cup in the medication cart and should have followed the appropriate procedures to discard the medications.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food safety and sanitation, which could potentially lead to the spread of foodborne illness among residents. Observations in the main kitchen revealed numerous mouse droppings and food particles on the shelf below the steam table, as well as on the floor between kitchen appliances and the wall. Additionally, an open drain under the steam oven was clogged with debris and covered in a grayish/black thick wet slime, with standing water around the drain opening. The staff break area adjacent to the walk-in refrigerator was found to have debris and food particles on the floor, with visibly dirty walls and an unlabeled, undated white bag containing food on the table. The dish room floor mat and the main kitchen ice machine drip tray were also observed to have significant buildup of black wet debris. In the basement dry storage area, the borders of the room under the shelves were found to have a buildup of debris and mouse droppings. The main dining room off the kitchen also had numerous mouse droppings in the cabinet below the main steam table. During an interview, the Food Service Manager acknowledged the presence of mice over a month ago and stated that the pest control company visits weekly. However, the manager admitted that the kitchen, steam tables, and basement should have been cleaned of all mice droppings, and the corners, behind kitchen appliances, the drain under the steam table, and the ice machine should have been cleaned. Further observations in the Applewood dining room and kitchenette revealed that the cabinets and drawers were dirty, with dried liquid stains and debris, and were tacky to the touch. The kitchenette contained expired food items, including Nepro, Thick and Easy, TwoCal, and Osmolite containers, as well as undated and unlabeled food items such as a bowl of oatmeal, a glass of milk, and eggs and sausages stored without temperature control. The Food Service Manager was aware of the issues with food storage in the kitchenettes and the expired supplement drinks, acknowledging that all food should be labeled, dated, and discarded if expired.
Inadequate Infection Control and Surveillance in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in relation to COVID-19 management. The facility's policy required outbreak testing and contact tracing when a COVID-19 case was identified, but the Infection Preventionist (IP) did not document contact tracing or testing of close contacts. The IP relied on staff to self-report positive COVID-19 tests without a system to verify compliance. The IP was unaware of updated guidelines and did not follow them, leading to inadequate management of the COVID-19 outbreak. The facility's infection surveillance system was also deficient. The IP used McGeer Criteria to identify healthcare-associated infections but did not track illnesses that did not require antibiotics. Monthly infection line listings only included residents who were prescribed antibiotics, failing to monitor the spread of illnesses among residents who did not receive antibiotics. This lack of comprehensive surveillance hindered the facility's ability to identify trends and manage infections effectively. Interviews with the Director of Nursing (DON) revealed an expectation for complete investigations of COVID-19 cases and comprehensive tracking of all illnesses, not just those treated with antibiotics. However, the facility's practices did not align with these expectations, resulting in incomplete documentation and inadequate infection control measures.
Failure in Catheter Care and Management
Penalty
Summary
The facility failed to provide appropriate indwelling catheter care and management for a resident, leading to a deficiency. The resident, who was readmitted to the facility with multiple diagnoses including neuromuscular dysfunction of the bladder and quadriplegia, had a Foley catheter inserted during a hospital stay due to urinary incontinence. Upon returning to the facility, the catheter was not assessed for removal, and there was no follow-up with a urologist as recommended. The facility's policy required ongoing assessment and documentation of the need for a catheter, with removal as soon as it was no longer necessary. However, the Foley Catheter Assessment form for the resident was left blank, indicating a lack of proper evaluation. Despite the family member's request for catheter removal and the resident's previous condition without a catheter, the facility did not conduct a voiding trial or schedule a urology appointment. The resident experienced complications, including blood clots from the urinary meatus, which prompted a hospital evaluation. Although the hospital discharge summary indicated no acute findings and recommended follow-up with a specialist, the facility's records showed no evidence of a scheduled urology appointment or further assessment of the catheter's necessity. This lack of action and documentation contributed to the deficiency identified by the surveyors.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Champion Rehabilitation And Nursing Center | 0.8 mi | ★★★★★ | 8 | 0 |
| Brockton Post Acute Care | 2.5 mi | ★★★★★ | 0 | 0 |
| The Guardian Center | 2.7 mi | ★★★★★ | 2 | 0 |
| Colony Center For Health And Rehabilitation | 2.9 mi | ★★★★★ | 1 | 0 |
| Alliance Health At West Acres | 3.1 mi | ★★★★★ | 6 | 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.