Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Nursing Home during CMS and state inspections, most recent first.
Expired food items were found in kitchen storage during a survey. A cook found opened bread products in the refrigerator past their expiration dates, and frozen meat items were also observed with old dates. The CDM/CFPP said bread was moved from the freezer for use but did not know how long it remained usable after thawing, and later admitted she created a bread-from-the-freezer policy only after the surveyor identified the expired items.
Resident Council concerns were not documented with the facility’s responses, actions, or rationale in writing. The DON provided undated and handwritten meeting materials, but review of the records did not show the concerns placed in the suggestion bag or any written response to them. The DON stated residents used the council to share ideas and concerns, but acknowledged that documentation of those issues and the facility’s response was not yet being done in writing.
Failure to notify provider of bleeding and decline in condition. A resident had repeated episodes of blood in stool and urine, along with increasing weakness, right-sided weakness, and a change in condition that led to needing full assistance with meals. The record showed ongoing documentation of these findings, but no evidence that the provider was notified when the bleeding and weakness first appeared.
Failure to Notify MD and Document Foley Catheter Re-insertions: A resident with an indwelling Foley catheter had the catheter dislodged or come out multiple times, and staff re-inserted it each time without evidence of MD notification or an order for re-insertion. The TAR showed routine monthly catheter changes, but there were no TAR entries or supporting clinical records for several additional re-insertions, and the DON confirmed the missing documentation and lack of physician notification.
Pharmacy recommendations were not timely addressed for two residents during MRR review. One resident had repeated unresolved guidance to clarify a diclofenac gel order, with the provider response documented later in the EHR, while another resident’s Tylenol order was left unclear because the MRR response was unsigned and undated and the med cart contained tablets even though the order was for capsules. The DON acknowledged the concern.
Medication orders lacked adequate indications for use for a resident with diagnoses including severe dementia, psychotic disturbance, mood disturbance, and anxiety. The resident was ordered candesartan, furosemide, Novolog, timolol, and Lumigan, but review of the record did not show an adequate indication for any of these medications. The DON acknowledged that medications should have an indication and agreed the concern was not good.
QAPI committee attendance records showed the required members did not consistently attend monthly QAPI meetings. The Medical Director missed 5 of 12 meetings and the NHA missed 1 of 12 meetings, and the IP/SE/QAPI Secretary reviewed and confirmed the attendance concerns.
A resident diagnosed with shingles had contact precaution signage posted at the room entrance, but the order for contact precautions was not entered until the next day. The IP stated that contact precautions are required for any resident with shingles and should be implemented at the same time as the diagnosis, and validated the delay.
The facility failed to monitor and document an employee’s COVID-19 vaccination status. During review of employee health files, a Dietary Aide hired in October 2024 was found to lack documentation of COVID-19 vaccination status. The IP stated that vaccination records are collected on hire and should include COVID-19, but the employee’s file did not contain this information.
The facility failed to store foods properly, as observed during a kitchen tour. Expired yogurts and an open, undated package of bacon were found in the refrigerator. The Certified Dietary Manager, responsible for food storage, stated she checks expiration dates daily and organizes products accordingly.
Expired Food Items Found in Kitchen Storage
Penalty
Summary
The facility failed to manage expired food items in the kitchen during the recertification survey. During an initial tour of the kitchen, the surveyor observed opened food items in the refrigerator with expiration dates that had passed, including an opened bag of bagels, raisin cinnamon bread, pumpernickel bread, white bread, and Hawaiian bread. In the basement walk-in freezer, the surveyor also found two foil-wrapped packs of ribs dated 11/22/25 and two 5-pound packs of low chicken dated 6/28/25. When asked about the items, Staff #24 stated they were for the sisters and did not know how long they could be kept or used, and he did not know how staff distinguished between food intended for the sisters and food for residents. The Certified Dietary Manager/Certified Food Protection Professional stated that all food items are marked with expiration dates and that staff are instructed to use freshly delivered bread first. She explained that bread nearing expiration is moved to the freezer, and said the bread found in the refrigerator had been moved there from the freezer for use. However, when asked how long bread remains viable in the refrigerator after being moved from the freezer, she stated she did not know. The next day, she provided a policy titled HACCP: Bread from the Freezer, which required store-bought bread to be frozen before the labeled expiration date, labeled with the date removed from the freezer, and used within 3 days once defrosted. She admitted she had researched and created the policy only after the surveyor brought the expired bread to her attention.
Resident Council Concerns Not Documented or Responded to in Writing
Penalty
Summary
The facility failed to have a system in place to ensure the Resident Council received responses, actions, and rationale regarding concerns raised by residents, and failed to document the facility’s response to those concerns. During review of documentation, the surveyor was provided a sheet titled “Resident Council News” with no date, along with seven typed pages that the DON stated she had prepared after receiving minutes on scrap pieces of paper. Review of those seven pages did not reveal any of the concerns submitted to the pink suggestion bag or any documentation of the facility’s response to those concerns. The DON stated the Resident Council had been meeting since about August 2025, and later showed an organizational folder with a list of original Resident Council members and a page listing meeting dates, with the first meeting documented as 3/29/25. She also provided two additional handwritten sets of Resident Council minutes. When asked about the purpose of the Resident Council, the DON stated residents used it to share concerns and suggestions such as food preferences, picnic timing, and activities. When asked whether there was documentation of issues or concerns shared by residents and/or families and the facility’s response, the DON stated that would need to be done in the future and that it was being done, but not in writing.
Failure to Notify Provider of Bleeding and Decline in Condition
Penalty
Summary
The facility failed to notify the provider of a resident’s blood in stool and urine and of a worsening weakness that progressed to the resident needing full assistance with meals. Resident #5 was documented on multiple occasions with blood in the bowel movement, blood on the incontinence brief, and blood in the toilet, along with increasing weakness, difficulty standing, and a change in condition that included being unable to feed self and needing staff to feed meals. The record also noted right-sided weakness, confusion when prompted to raise the right arm, and later continued weakness and fatigue. The medical record showed ongoing documentation of blood in stool and urine, weakness, and decreased ability to perform activities of daily living, but there was no evidence that the provider was notified when these changes first occurred. The care plan included monitoring and reporting blood in stool and signs and symptoms of anemia, including weakness and changes in mental status. During interview, the DON stated that blood in stool, urine, or an incontinence brief and a change in condition should be reported to the charge nurse and the provider notified during that shift, but the surveyor found no evidence in the record that this occurred after the resident’s bleeding and weakness were observed.
Failure to Notify Physician and Document Foley Catheter Re-insertions
Penalty
Summary
The facility failed to notify the physician regarding the status of a resident's indwelling Foley catheter and failed to obtain physician orders for catheter re-insertions. During review of Resident #7's medical records from November 2025 through January 2026, progress notes showed the Foley catheter was found dislodged or came out on six occasions: 11/13/25, 11/20/25, 11/26/25, 12/04/25, 12/16/25, and 1/15/26. The notes indicated the catheter was re-inserted each time, but there was no evidence that the physician was notified or that an order was obtained for the re-insertion. Review of the TAR on 1/22/26 showed an order to change the 16 French/10cc balloon catheter every 30 days for hygiene and infection control. The monthly changes were initialed on 11/10/25, 12/10/25, and 1/15/26, but there were no TAR entries or supporting clinical records for the five additional re-insertions that occurred between November and December. The DON stated that a provider's order is required for Foley catheter re-insertion or change and that these events must be documented in both the progress notes and the TAR; upon review with the surveyor, the DON validated that the re-insertions were not documented in the TAR and that there was no evidence of physician notification or obtained orders.
Pharmacy Recommendations Not Timely Addressed
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for 2 residents reviewed for unnecessary medications during the recertification survey. The Medication Regimen Review process was described by the DON as involving the pharmacist emailing the review report, with recommendations then faxed or called to the physician and placed in a rolling cart for follow-up. The facility policy stated that non-urgent recommendations must be addressed in a timely manner, no later than the next routine visit, and the attending physician should document the irregularity reviewed, the action taken, and the rationale if the recommendation is not accepted. For one resident, the pharmacist issued a recommendation on the monthly medication regimen review to complete the diclofenac topical gel order by adding a dose per application. A later monthly review repeated the same recommendation, and the record showed no documentation that the earlier recommendation had been addressed. The later response was signed and dated by the provider, with a handwritten note that it was fixed in the electronic record the next day. The resident’s medication order was then revised to include 2 gm, but the earlier recommendation had remained unresolved in the record until the repeated review. For another resident, the pharmacist recommended clarifying whether Tylenol 325 mg was being given as capsules or tablets and correcting the order if tablets were actually being used. The review contained a handwritten response stating capsules per order, but it was undated and unsigned. When the surveyor and RN inspected the medication cart, the package contained Tylenol 325 mg tablets even though the order was for capsules. The DON later acknowledged the concern, and the surveyor determined that the pharmacist’s recommendation had not been appropriately addressed or resolved.
Medication Orders Lacked Adequate Indications
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met when the facility failed to ensure medications were ordered with an adequate indication for use for Resident #8. Review of the resident's medical record showed admission with diagnoses including unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident had orders for candesartan cilexetil 16 mg daily, furosemide 20 mg daily, Novolog 20 units subcutaneously before meals, timolol maleate ophthalmic solution 0.5% one drop in both eyes in the morning, and Lumigan ophthalmic solution 0.01% one drop in both eyes at bedtime, and review of these orders did not reveal an adequate indication for any of the medications. During interview, the DON stated that medications should have an indication and acknowledged the concern when informed that 5 of 8 medications for the resident did not have an indication.
QAPI Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure the required QAPI committee members consistently attended monthly Quality Assurance and Performance Improvement meetings. Review of the facility’s QAPI attendance records for 1/2025 through 12/2025 showed that the Medical Director did not attend 5 of 12 meetings, missing the meetings in May, August, September, November, and December 2025. The Nursing Home Administrator did not attend 1 of 12 meetings, missing the May 2025 meeting. During interview, the Infection Preventionist/Staff Educator/QAPI Secretary reviewed the 2025 attendance sheets, verified the surveyor’s findings, and confirmed the attendance concerns.
Delayed Contact Precaution Order for Resident with Shingles
Penalty
Summary
The facility failed to maintain an effective infection control program by not ordering contact precautions in a timely manner for one resident diagnosed with shingles. During the facility tour, contact precaution signage was observed posted at the entrance to the resident’s room. Record review showed that the resident was diagnosed with shingles by the attending provider, but the order for contact precautions was not entered until the following day. The Infection Preventionist stated that contact precautions are required for any resident diagnosed with shingles and that the precaution order should be implemented at the same time as the diagnosis, and validated the surveyor’s concern about the delay.
Missing COVID-19 Vaccination Documentation for Employee
Penalty
Summary
The facility failed to ensure that an employee’s COVID-19 vaccination status was monitored and documented. During review of five randomly selected employee health files, Staff #17, a Dietary Aide hired in October 2024, was found to lack documentation supporting COVID-19 vaccination status. The Infection Preventionist stated that the facility collects copies of vaccination records upon hire and reviews immunization status for new employees, including Flu, MMR, Hepatitis B, Tdap, Varicella, TB, and COVID-19. A joint review of Staff #17’s health record confirmed that the file did not contain COVID-19 vaccination status, and the Infection Preventionist validated the finding.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to store foods in a manner that protects them from contamination and spoilage, as observed during an initial kitchen tour. During the tour, a box of six yogurts with an expired date was found in the large walk-in refrigerator. Additionally, an open and undated package of bacon was observed sitting on an open rack above open containers of produce. These findings were confirmed by a staff member, who subsequently discarded the expired and improperly stored items. An interview with the Certified Dietary Manager revealed that she is responsible for storing perishable foods and checks expiration dates daily, ensuring newer products are placed behind older ones on the shelves.
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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 Catonsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Summit Park | 0.9 mi | ★★★★★ | 26 | 0 |
| Autumn Lake Healthcare At Catonsville | 1.1 mi | ★★★★★ | 41 | 0 |
| Forest Haven Nursing And Rehabilitation Ctr | 1.4 mi | ★★★★★ | 54 | 0 |
| Little Sisters Of The Poor | 1.9 mi | ★★★★★ | 5 | 0 |
| Charlestown Community Inc | 1.9 mi | ★★★★★ | 22 | 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.