Below 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 Carriage Square Rehab And Healthcare Center during CMS and state inspections, most recent first.
Surveyors were unable to timely review necessary records due to the facility’s failure to promptly provide access to the EMR, resident roster, and resident matrix after these items were requested from the Administrator and DON. The Administrator initially supplied only a staff list and withheld EMR access and resident information pending authorization from regional corporate staff, in accordance with the company’s stated protocol that documentation be reviewed by regional team members before release. As a result, surveyors did not receive EMR access and the resident matrix until several hours after the initial request, and no policy addressing timely access to medical records was provided.
Two residents with indwelling urinary catheters did not receive proper catheter care, as staff failed to keep catheter bags off the floor and used improper cleaning techniques, such as reusing soiled wipes and not changing gloves. Staff interviews revealed gaps in knowledge of infection control protocols, contributing to the risk of catheter-associated urinary tract infections.
Staff failed to consistently use enhanced barrier precautions and proper infection control measures during high-contact care for residents with wounds and indwelling devices. Observations included staff not performing hand hygiene, not wearing gowns, not changing gloves after contamination, and allowing catheter bags to touch the floor. These lapses occurred during wound care and catheter care for several residents, despite staff awareness of required protocols.
Staff failed to follow the facility's policy for handling medical record requests, with some staff printing and distributing records without formal written requests. Additionally, a resident's representative experienced significant delays in receiving requested medical records, as the required procedures and documentation were not followed and records were not provided within the required timeframe.
Staff failed to follow proper perineal care and infection control procedures for three residents who were incontinent, including reusing soiled wipes on multiple areas and not changing gloves after care. These residents, who required assistance with hygiene and had histories of incontinence and UTIs, did not receive care in accordance with facility policy, as confirmed by staff interviews and direct observation.
A resident with a history of pneumonia and UTI experienced a significant change in condition, including low blood pressure and confusion, but the facility failed to notify the physician promptly. An ordered antibiotic was not administered due to lack of access, and a urinalysis was delayed, leading to the resident's hospitalization for sepsis. Interviews revealed communication failures and non-compliance with the facility's change of condition policy.
A resident with spinal stenosis and inflammatory spondylopathy experienced severe pain due to the facility's failure to order oxycodone in a timely manner, resulting in five missed doses. The resident reported extreme pain and withdrawal-like symptoms, and interviews revealed that the medication was ordered late and sent to the wrong physician. The DON acknowledged the error and emphasized the need for timely reordering of medications.
The facility's Arbitration Agreement failed to include a clause stating that signing was not a condition for admission or continued care, affecting all residents who signed it. Staff interviews confirmed the omission, with the Admission Coordinator, Regional Director, and Administrator unaware of the missing clause.
The facility failed to designate a qualified Infection Preventionist (IP) with specialized training to manage the Infection Prevention and Control Program (IPCP). The Minimum Data Set Coordinator (MDSC) was acting as the IP without formal training or certification, and the facility had been without a qualified IP since October 2024. The Assistant Director of Nursing (ADON) was being trained for the role, but the MDSC continued to perform IP duties. This deficiency placed all 93 residents at risk for infections.
The facility failed to maintain an effective training program, missing cultural competency training and lacking a system to track staff attendance for required in-services. This deficiency potentially allowed staff to work without necessary skills, risking negative outcomes for residents.
The facility did not maintain an effective training program, failing to provide required annual training on effective communication for direct care staff. The Performance Improvement Plan revealed that the necessary 12 hours of training were not consistently scheduled or completed. The Administrator admitted the lack of a tracking system and a staff educator, leading to incomplete training.
The facility did not maintain an effective training program for staff on the Quality Assurance and Performance Improvement (QAPI) program. The required annual 12 hours of training were not consistently scheduled or completed. The 2024 in-service calendar lacked QAPI as a training topic, and no such training was provided. The Administrator admitted to the absence of a tracking system for training attendance and the lack of a staff educator, with the former DON unable to cover all educational needs.
The facility failed to provide annual training on compliance and ethics for all staff, as required. The Performance Improvement Plan identified that the necessary 12 hours of training were not consistently scheduled or completed. There was no evidence of compliance training being provided in 2024, and the facility lacked a tracking system to identify staff who missed the training. The absence of a staff educator contributed to this deficiency.
The facility failed to provide the required 12 hours of annual in-service training for CNAs, as mandated by regulation. The absence of a consistent training schedule and tracking system led to CNAs potentially working without necessary skills. The facility's assessment outlined essential training topics, but the 2024 in-service calendar did not include all required trainings, and attendance was not tracked. The Administrator acknowledged the lack of a staff educator and tracking system, which could impact the care provided to the facility's 93 residents.
The facility failed to maintain respiratory care equipment and follow physician orders for three residents. A resident's oxygen concentrator filter was found dirty, contrary to policy. Another resident's oxygen was set at four LPM instead of the ordered two LPM, risking hypoxia or over-oxygenation. A third resident's oxygen was set at 2.5 liters instead of the ordered three liters. These failures risked respiratory complications.
The facility failed to maintain kitchen cleanliness and proper food storage, risking foodborne illnesses for residents. Observations included wet-stacked pans, dirty containers, and unlabeled food items in storage. The ADM confirmed these issues, indicating a lack of knowledge about use-by dates.
The facility failed to maintain an effective infection prevention and control program, with lapses in infection surveillance, water management, and glucometer disinfection. The MDSC did not update infection records due to the absence of an IP, and the Maintenance Director neglected to test the water fountain's pH levels. An LPN failed to clean a glucometer between residents, contrary to protocol.
The facility failed to develop comprehensive care plans for two residents, one receiving hospice services and another with diabetes mellitus. The hospice care plan for a resident was not completed, and another resident's care plan lacked focus on diabetes management, despite physician orders for regular blood sugar checks. These omissions risked unmet care needs.
A medication error occurred when a CMT, distracted while preparing medications, administered another resident's medications to a resident with multiple diagnoses, including a femur fracture and anemia. The error was discovered after the resident questioned the number of medications received, leading to an immediate assessment by an RN, which found no adverse reactions. The CMT failed to follow proper medication administration protocols, such as verifying the resident's identity.
A facility failed to maintain an effective antibiotic stewardship program when a resident with a UTI did not receive an infection screening evaluation to ensure the correct antibiotic was prescribed. The facility also lacked documentation of antibiotic usage tracking and infection occurrences. The MDSC had not completed necessary evaluations since January and was not fully trained, while the administrator and regional nurse consultant cited staffing challenges.
The facility did not provide necessary staff education following allegations of inappropriate conduct by staff towards two residents, one with moderate cognitive impairment and physical limitations, and another who was cognitively intact but physically dependent. Despite these incidents, no additional training on abuse and neglect was conducted, violating the facility's policy.
The facility failed to report allegations of sexual abuse involving two residents to law enforcement and the Department of Health and Senior Services within the required timeframe. In one case, a Physical Therapist Assistant was observed with their hand inside a resident's brief, but the Administrator did not contact law enforcement. In another case, a resident reported inappropriate touching, but the Administrator did not report it due to the resident's history of delusions. The facility did not follow its policy requiring immediate reporting of such incidents.
The facility failed to properly investigate allegations of inappropriate conduct by PTAs with residents. In one case, a CNA reported seeing a PTA with their hand inside a resident's brief, but the facility did not notify the physician or law enforcement. In another case, a resident alleged inappropriate touching by a PTA, but the facility dismissed the claim due to the resident's history of delusions. Both incidents show a failure to follow the facility's abuse prevention policy.
Failure to Provide Timely Access to EMR and Resident Matrix for Surveyors
Penalty
Summary
The facility failed to provide timely access to resident electronic medical records (EMR), a staff list, and a resident matrix needed by surveyors to conduct a survey and review care provided to residents. On 1/27/2026 at 9:50 A.M., the Administrator and DON were given a list of required items, including the resident matrix and EMR access, to conduct an abbreviated survey process. By 11:19 A.M., the Administrator had only provided a staff list and stated he would not provide EMR access, the resident roster, or the resident matrix until he received authorization from regional team members. Surveyors did not receive EMR access and the resident matrix until 12:42 P.M., delaying their ability to review necessary records. The Administrator later stated that the company protocol required documentation to be reviewed by regional corporate team members before being provided to surveyors, and no facility policy regarding timely access to medical records was provided.
Deficient Catheter Care and Infection Control Practices
Penalty
Summary
The facility failed to provide appropriate catheter care management for two residents with indwelling urinary catheters, resulting in deficiencies related to the prevention of urinary tract infections (UTIs). One resident with a suprapubic catheter and limited mobility was observed with their catheter bag touching the floor while seated in a wheelchair, and staff did not secure the bag off the floor during care. Additionally, catheter care was performed improperly, with a CNA using the same soiled wipe in a back-and-forth motion on the catheter tubing and not changing gloves after touching other items. This resident had a recent history of urinary retention and was diagnosed with a UTI associated with the indwelling catheter, requiring antibiotic treatment and catheter replacement. Another resident, also dependent on staff for catheter and incontinence care, was observed receiving catheter care in which the tubing was scrubbed in a back-and-forth motion, contrary to facility policy. Interviews with staff revealed a lack of knowledge regarding proper catheter care techniques, such as using a new wipe for each swipe and ensuring catheter bags and tubing do not touch the floor. Staff acknowledged difficulties in keeping catheter bags off the floor and inconsistencies in following infection control protocols, including hand hygiene and glove changes.
Failure to Implement Infection Prevention and Control Measures During High-Contact Care
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in the use of enhanced barrier precautions (EBP) and personal protective equipment (PPE) during high-contact care for residents with wounds and indwelling devices. Observations revealed that staff did not consistently perform hand hygiene, wear gowns, or change gloves appropriately when providing wound care and catheter care. For example, a registered nurse and a licensed practical nurse did not wear protective gowns or perform hand hygiene between glove changes while changing dressings on a resident with chronic leg wounds and a catheter. The same staff touched their faces, handled contaminated items, and continued care without changing gloves or sanitizing hands, despite the resident's recent hospitalizations for wound infections and cellulitis. Another incident involved the facility's infection preventionist, who placed a resident's dirty sock on top of clean wound dressing supplies during a dressing change for a pressure ulcer. The infection preventionist continued the procedure without changing gloves or obtaining new supplies after contamination occurred. The director of nursing confirmed that staff were expected to change gloves and retrieve new supplies if contamination happened, but this protocol was not followed during the observed care. Additionally, staff failed to follow proper catheter care protocols for residents with indwelling urinary catheters. Observations showed that catheter bags were allowed to touch the floor, and staff did not wear isolation gowns or change gloves after handling potentially contaminated items such as trash cans before providing catheter care. Interviews with staff and the director of nursing confirmed awareness of the correct procedures, but these were not implemented during the observed care. These failures were noted for multiple residents who were dependent on staff for wound and catheter care.
Failure to Follow Medical Record Request Policy and Timely Release of Records
Penalty
Summary
The facility failed to follow its own policy regarding the handling of medical record requests and the safeguarding of resident-identifiable information. Staff members reported printing and providing copies of electronic medical records to residents and their representatives without obtaining a formal written request, as required by facility policy. The policy specified that all requests for access to protected health information (PHI) must be in writing and directed to the HIPAA Privacy Officer, with a specific form to be completed. However, interviews revealed that LPNs would print and hand over records directly to residents or their representatives, bypassing the required process. The Medical Records Director was unaware that nursing staff were distributing records in this manner and confirmed this was not the correct procedure. Additionally, the facility failed to provide requested medical records in a timely manner for a previous resident. The resident's representative made multiple written and verbal requests for records over several months, but the records were not provided within the state-specified time period. The Medical Records Director acknowledged delays in receiving and processing requests, citing that some requests were found at nurses' stations months after submission and that approval from the corporate office was required before releasing records. There was no documentation of the required request form being completed for the resident in question, and the records had still not been sent at the time of the surveyor's review.
Improper Perineal Care and Infection Control Practices
Penalty
Summary
Facility staff failed to provide appropriate perineal care to residents who were incontinent of bowel and/or bladder, as observed in three sampled residents. The facility's policy required perineal care to be performed at least daily and as needed, using clean soapy washcloths or wipes, moving from front to back, and using a clean area of the washcloth or a new wipe for each stroke. However, observations revealed that staff repeatedly used the same soiled wipe to clean multiple areas of the perineal region, rather than discarding wipes after a single use. In some cases, staff also failed to change gloves after providing perineal care and before applying a new incontinent brief, contrary to facility policy and standard infection control practices. The residents involved were dependent on staff for personal care and hygiene, with medical histories including frequent or occasional incontinence, cognitive impairment, and recent or ongoing treatment for urinary tract infections. Staff interviews confirmed improper perineal care techniques, such as reusing wipes and not changing gloves, while other staff and the Director of Nursing stated that wipes should be used once and gloves changed after care. These actions and inactions resulted in a failure to provide appropriate care and services to prevent urinary tract infections and to restore continence to the extent possible.
Failure to Notify Physician and Administer Treatment Leads to Resident Hospitalization
Penalty
Summary
The facility failed to notify the physician in a timely manner when a resident experienced a change in condition, failed to start an antibiotic that was ordered by the resident's physician, and failed to obtain a physician-ordered urinalysis (UA) in a timely manner. These failures involved a resident who was admitted with diagnoses including pneumonia, urinary tract infection (UTI), and retention of urine. The resident was emergently discharged to the hospital due to sepsis related to a UTI. The resident's vital signs showed a significant drop in blood pressure over several days, indicating a change in condition. Despite these changes, the attending physician was not notified promptly. The resident's family requested an antibiotic, which was ordered but not administered because the staff did not have access to the medication. Additionally, a urinalysis was ordered but not collected until over 24 hours later, delaying the diagnosis and treatment of the UTI. Interviews with staff revealed a lack of communication and failure to follow the facility's policy on change of condition notification. The Director of Nursing stated that a drastic change in blood pressure or mental status should have prompted notification of the physician. The Advanced Practice Registered Nurse and Medical Doctor confirmed they were not informed of the resident's low blood pressure or the delay in obtaining the urinalysis, which would have led to immediate hospital transfer to rule out sepsis.
Failure to Manage Pain Effectively for a Resident
Penalty
Summary
The facility failed to effectively manage pain for a resident, identified as R71, who was prescribed oxycodone for pain management. The resident was admitted with conditions including spinal stenosis and unspecified inflammatory spondylopathy of the lumbar region, and was assessed to have a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness. The resident's pain was frequently rated at a 7 on a numeric scale of 0-10, and he was prescribed oxycodone 10mg/325mg every 6 hours. However, the facility did not order the medication in a timely manner, resulting in the resident missing five doses over two days. This led to the resident experiencing severe pain, inability to sleep, and symptoms resembling withdrawal. Interviews revealed that the Certified Medication Technician (CMT) had informed the Assistant Director of Nursing (ADON) about the medication running out, but the issue was not resolved promptly. The Director of Nursing (DON) acknowledged that the medication was ordered late and sent to the wrong physician, and emphasized that the medication should have been reordered five to six days before the last dose. The resident expressed significant distress due to the missed medication, reporting a pain level of 10 out of 10 and continued severe pain affecting his entire body.
Arbitration Agreement Lacks Required Clause
Penalty
Summary
The facility failed to ensure that the Arbitration Agreement presented to residents and their representatives during admission included a clause stating that signing the agreement was not a condition for admission or continued care. This omission affected all residents who had signed the Arbitration Agreement and any future residents who might sign it. The facility's policy on arbitration, dated October 24, 2022, indicated that the agreement should comply with federal and state laws and that signing was not a requirement for admission or continued treatment. However, the actual agreement, revised in July 2022, did not include this critical clause. Interviews with facility staff, including the Admission Coordinator, the Regional Director of Clinical and Reimbursement Services, and the Administrator, confirmed the absence of the necessary clause in the arbitration agreement. The Admission Coordinator acknowledged that the agreement was developed by the corporation and used across all their facilities. Both the Regional Director and the Administrator were unaware of the omission, indicating a lack of oversight in ensuring the agreement's compliance with stated policies and regulations.
Lack of Designated and Trained Infection Preventionist
Penalty
Summary
The facility failed to ensure there was a designated Infection Preventionist (IP) with specialized training in infection prevention and control, which is necessary for the effective management of the Infection Prevention and Control Program (IPCP). The Minimum Data Set Coordinator (MDSC) was identified as the acting IP, but she had not completed any formal infection preventionist training and lacked certification. The MDSC also indicated that she did not have sufficient time to oversee the IPCP while fulfilling her duties as the MDSC. The facility had been without a qualified IP since October 2024, and a nurse hired for the position vacated it within a month. Interviews revealed that the Assistant Director of Nursing (ADON) was being trained for the IP role, but the MDSC was still performing the IP duties. The Regional Nurse Consultant mentioned that a Licensed Practical Nurse (LPN) was overseeing the program and had completed IP training, but the LPN clarified that she was not the current IP and did not oversee the program. This lack of a designated and trained IP placed all residents at risk for acquiring diseases and infections, as the facility census was 93.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for all staff members, as required by their facility assessment. Specifically, the facility did not provide cultural competency training in 2024, despite it being identified as a need. Additionally, while training on abuse and neglect, infection control, and behavioral health was provided, the facility lacked a system to monitor which staff members had completed the training. This deficiency potentially allowed staff to work without the necessary skills to care for the resident population, placing all residents at risk for negative healthcare outcomes. The facility's Performance Improvement Plan (PIP) acknowledged that the required annual 12 hours of training had not been consistently scheduled or completed by all staff. The PIP outlined a plan for Human Resources and the Administrator to schedule the required in-services and track attendance. However, the facility did not have a staff educator, and the former Director of Nursing could not continue to provide all the required education. This lack of a tracking system was evident in several instances, including behavior management training and enhanced barrier precautions training, where there was no record of which staff attended.
Deficiency in Staff Training on Effective Communication
Penalty
Summary
The facility failed to maintain an effective training program for all staff, specifically lacking training on effective communication for direct care staff. The Performance Improvement Plan (PIP) dated 12/13/24 identified that the required annual 12 hours of training had not been consistently scheduled or completed by all staff. The facility's assessment dated 08/06/24 indicated that CNAs were supposed to receive annual education on effective communication, but the in-service calendar for 2024 showed that this training was not provided. During an interview, the Administrator acknowledged the absence of a tracking system to identify staff who missed training and noted that the former Director of Nursing had been unable to provide all the required education due to the lack of a dedicated staff educator.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to maintain an effective training program for all staff, specifically regarding the Quality Assurance and Performance Improvement (QAPI) program. The Performance Improvement Plan (PIP) dated 12/13/24 identified that the required annual 12 hours of training had not been consistently scheduled or completed by all staff. The plan outlined that Human Resources (HR) and the Administrator were responsible for obtaining the list of required in-service trainings and scheduling them, but this was not effectively implemented. The review of the 2024 in-service calendar revealed that QAPI was not included as a training topic, and no such training was provided to the staff. During an interview, the Administrator acknowledged the lack of a tracking system to identify staff who missed training and noted the absence of a staff educator, with the former Director of Nursing (DON) unable to provide all the required education.
Deficiency in Staff Training on Compliance and Ethics
Penalty
Summary
The facility failed to maintain an effective training program for all staff, specifically regarding the annual training on compliance and ethics program standards, policies, and procedures. This deficiency was identified through interviews, record reviews, and facility policy review. The facility's Performance Improvement Plan (PIP) dated 12/13/24 revealed that the required 12 hours of annual training had not been consistently scheduled or completed by all staff. The PIP outlined a plan for Human Resources and the Administrator to schedule the required in-services, but there was no documented evidence that the compliance training was provided in 2024. The Administrator acknowledged the lack of a tracking system to identify staff who missed the training and noted the absence of a staff educator, with the former Director of Nursing unable to provide all the required education.
Deficiency in CNA Continuing Education Program
Penalty
Summary
The facility failed to maintain an effective continuing education program for Certified Nurse Aides (CNAs), as required by regulation, which mandates 12 hours of in-service training annually. The facility's policy outlined the necessity for CNAs to complete this training to ensure competency in providing care to residents. However, the facility did not consistently schedule or track the required in-service trainings, leading to CNAs potentially working without the necessary education and skills. The facility's Performance Improvement Plan (PIP) acknowledged this issue, noting that the required training topics were not consistently offered, and there was no system in place to track CNA attendance or completion of the training. The facility's assessment indicated that CNAs were to receive annual education on various critical topics, including dementia care, abuse prevention, and infection control, among others. Despite this, the in-service calendar for 2024 did not reflect all necessary trainings, and there was no documentation of the length of the in-services or the CNAs who attended. The Administrator confirmed the lack of a tracking system and the absence of a staff educator, with the former Director of Nursing unable to fulfill all educational requirements. This deficiency in the training program potentially compromised the quality of care provided to the facility's 93 residents.
Failure to Maintain Respiratory Care Equipment and Follow Physician Orders
Penalty
Summary
The facility failed to maintain respiratory care equipment and provide respiratory care per physician orders for three residents. Resident 15's oxygen concentrator was observed with a filter covered in dust, indicating it had not been cleaned as required by the facility's policy. The Licensed Practical Nurse (LPN) confirmed the filter was dirty and should have been cleaned weekly when the oxygen tubing was changed. The Director of Nursing (DON) also stated that the filter should be cleaned every time the oxygen tubing is changed. Resident 53, who was cognitively intact, had a physician's order for oxygen to be administered at two liters per minute (LPM) via nasal cannula. However, observations revealed the oxygen concentrator was set at four LPM on multiple occasions. An LPN verified the incorrect setting and adjusted it to the correct flow rate. The DON stated that nurses are expected to follow physician orders and check the oxygen concentrator's level regularly. The incorrect flow rate could lead to hypoxia or over-oxygenation, especially in residents with COPD. Resident 41, who was also cognitively intact, had a physician's order for oxygen at three liters via nasal cannula. Observations showed the oxygen concentrator's flow rate was set at 2.5 liters on multiple occasions. An LPN and the Regional Nurse Consultant (RNC) confirmed the incorrect setting. The RNC verified the physician's order and acknowledged the discrepancy. These failures in maintaining proper oxygen flow rates and equipment cleanliness placed residents at risk for respiratory complications.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. Several deficiencies were noted, including wet stacking of large metal sheet pans, a dirty plastic container of sugar packets with dried food particles, and a clean industrial stand mixer that was uncovered and had empty boxes stacked on it. Additionally, 13 clean metal pots and pans were stored on a dirty shelf with dried food particles. These observations indicate a lack of adherence to the facility's policy on pot and pan cleaning, which requires air drying without the use of towels. Further deficiencies were observed in the storage of food items. The walk-in refrigerator contained multiple items that were not labeled, dated, or had use-by dates, including rice, cream of wheat, beef broth, ketchup, soup, and cream of chicken soup. The walk-in freezer had a box of omelets that were not sealed and bags of calzones and sausage without use-by dates. The dry storage room contained a bag of spaghetti and individually wrapped slices of bread without dating. The Assistant Dietary Manager confirmed these observations and admitted a lack of knowledge regarding use-by dates, which could lead to uncertainty about the usability of food items. These failures placed all residents at risk for foodborne illnesses.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program (IPCP) as evidenced by several deficiencies. Firstly, the Minimum Data Set Coordinator (MDSC) admitted to not updating the infection surveillance binder, failing to track and trend infection incidents, and not recording corrective actions for several months. This lapse occurred because the facility had been without an Infection Preventionist (IP) since October 2024, and the MDSC was attempting to manage the infection surveillance until a new IP was hired or trained. The Administrator acknowledged the incomplete aspects of the IPCP due to staffing issues, and the Regional Nurse Consultant was unaware of the lapse in infection surveillance. Secondly, the facility's Maintenance Director did not implement measures to prevent the growth of water-borne pathogens in the water fountain, as identified in the facility's Water Management Program Risk Assessment. The Maintenance Director admitted to forgetting to test the water fountain's pH levels, despite testing the water throughout the building weekly. The Regional Director of Plant Operations, responsible for monitoring the testing, had not identified the oversight since the risk assessment was completed in June 2024. Lastly, the facility staff failed to clean and disinfect a multi-use glucometer between residents as per the manufacturer's instructions. During an observation, an LPN used the glucometer on two residents without cleaning it between uses. The LPN admitted to forgetting to clean the device and did not follow the instructions on the disinfecting wipe container. The Regional Director of Clinical and Reimbursement Services confirmed that staff are trained to clean and disinfect glucometers according to protocol, and the Director of Nursing stated that the expectation is for nursing staff to follow infection control practices and policies.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, R74 and R10, which reflected their current medical needs. R74, who was receiving hospice services, did not have a care plan that included hospice care, despite the facility's policy requiring coordinated care plans for residents receiving such services. The Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) acknowledged that a hospice care plan should have been completed when R74 started receiving hospice services. Similarly, R10, who was diagnosed with diabetes mellitus and had physician orders for regular blood sugar checks, did not have a care plan addressing their diabetic care. The MDSC confirmed that R10's care plan was incomplete, lacking focus, measurable goals, or interventions related to diabetes management. These omissions in care planning placed the residents at risk of having unmet care needs.
Medication Error Due to Distraction
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A Certified Medication Technician (CMT) mistakenly administered medications intended for another resident to Resident 89. This error occurred when the CMT, after preparing the medications for Resident 147, became distracted and inadvertently entered Resident 89's room, administering the wrong medications. The medications given included metoprolol tartrate, metformin, gabapentin, glipizide, and simvastatin, none of which were ordered for Resident 89 by her physician. Resident 89, who was moderately cognitively impaired, was admitted to the facility with multiple diagnoses, including a fracture of the left femur, acute posthemorrhagic anemia, and urinary incontinence. At the time of the incident, Resident 89 was not on any high-risk drug class medications and had no known drug allergies. The error was discovered when the CMT realized the mistake after Resident 89 questioned the number of medications she received, prompting the CMT to check the orders and report the error to a Registered Nurse (RN). The RN assessed Resident 89 immediately after being informed of the error and found her vital signs to be stable with no signs of adverse reactions. The Director of Nursing (DON) was notified, and an investigation revealed that the CMT did not follow the medication administration rights, such as verifying the resident's identity with at least two identifiers. The DON confirmed that the CMT had not been monitored for medication errors since the incident, although no further errors had been reported.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure an effective antibiotic stewardship program, as evidenced by the Minimum Data Set Coordinator (MDSC) not completing an infection screening evaluation for a resident diagnosed with a urinary tract infection (UTI). This oversight occurred for one of four residents reviewed for UTIs out of a sample of 33 residents. The resident in question was admitted with a diagnosis of UTI, and despite a physician's order for a urine culture, the MDSC did not perform the necessary evaluation to confirm the appropriateness of the prescribed antibiotic, Cephalexin. The laboratory results indicated mixed gram-negative and gram-positive organisms and yeast, yet the MDSC failed to assess whether the correct antibiotic was ordered, which is a critical step in preventing antibiotic resistance. Additionally, the facility's Antibiotic Stewardship Program lacked documentation of tracking or trending antibiotic usage and infection occurrences within the facility. The Monthly Infection Log for February and March 2025 showed that infection screening evaluations were not completed. Interviews revealed that the MDSC had not conducted infection screening evaluations for residents on antibiotics since January 2025 and had not completed infection preventionist training. The facility's administrator and regional nurse consultant acknowledged the gaps in the infection control program, citing staffing challenges as a contributing factor.
Failure to Implement Abuse and Neglect Policy
Penalty
Summary
The facility failed to implement its abuse and neglect policy by not providing necessary education to staff following two separate allegations of inappropriate conduct by staff members towards residents. The first incident involved an alleged sexual assault on a resident with moderate cognitive impairment and physical limitations, including dementia and mobility issues. The second incident involved inappropriate touching of a resident who was cognitively intact but had significant physical limitations, including dependency on a wheelchair and assistance for mobility and toileting. Despite these serious allegations, the facility did not conduct any additional training on abuse and neglect for its staff after being made aware of the incidents. The Director of Nursing confirmed that the last training session was conducted prior to these events, and the Administrator admitted to not providing further training following the new allegations. This lack of action contravenes the facility's policy, which mandates regular and situational training to prevent and address abuse and neglect.
Failure to Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual assault involving a resident to law enforcement. A Certified Nurse Aide observed a Physical Therapist Assistant with their hand inside a resident's brief, but the Administrator did not contact law enforcement, believing it was not necessary as it was not rape. The Director of Nursing also did not think law enforcement should be contacted since the alleged perpetrator was removed from the building and the resident was protected. The resident involved had moderately intact cognition but was dependent on staff for various needs due to cognitive and physical impairments. In another incident, the facility did not report an allegation of sexual abuse to the Department of Health and Senior Services within the required two-hour timeframe. A resident reported inappropriate touching by a Physical Therapist Assistant, but the Administrator did not report the allegation due to the resident's history of delusions and the belief that the allegation was untrue. The resident was cognitively intact but had functional limitations and was dependent on a wheelchair. The facility's policy requires immediate reporting of suspected criminal sexual abuse to the Administrator and Director of Nursing Services, who must then notify proper authorities within two hours. However, in both cases, the facility did not adhere to this policy, resulting in a failure to report the allegations to the appropriate authorities in a timely manner.
Failure to Investigate Allegations of Inappropriate Conduct
Penalty
Summary
The facility failed to conduct a thorough investigation and follow proper procedures in response to allegations of inappropriate conduct by Physical Therapy Assistants (PTAs) with residents. In the first incident, a Certified Nurse Aide (CNA) reported observing PTA A with his hand inside a resident's brief. The facility did not notify the physician, contact law enforcement, or have the resident assessed for a medical exam. The investigation was deemed unsubstantiated based on the lack of witnesses and the denial by PTA A, despite the CNA's detailed account of the incident. In the second incident, another resident alleged that PTA B touched them inappropriately. The facility again failed to notify the physician and did not conduct a thorough investigation. The resident reported feeling uncomfortable with PTA B's actions, which included touching their leg and making inappropriate comments. Despite the resident's clear account and history of similar allegations, the facility did not report the incident to the appropriate authorities, citing the resident's history of delusions as a reason for dismissing the claim. Both incidents highlight significant lapses in the facility's adherence to its abuse prevention and prohibition program. The facility's policy mandates immediate reporting and thorough investigation of such allegations, including notifying law enforcement and conducting medical assessments. However, these steps were not followed, resulting in a failure to protect the residents and ensure their safety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 132 citations issued within 25 miles in the last 12 months — including the 5 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Joseph
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Joseph Manor Health & Rehabilitation | 1 mi | ★★★★★ | 2 | 0 |
| Living Community Of St Joseph | 1.5 mi | ★★★★★ | 0 | 0 |
| Advanced Care Of St Joseph | 2.3 mi | ★★★★★ | 2 | 0 |
| Belleview Care Center | 3 mi | ★★★★★ | 2 | 0 |
| St Joseph Chateau | 3.1 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.