Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Living Community Of St Joseph during CMS and state inspections, most recent first.
Surveyors found multiple medication labeling and storage deficiencies on cart inspections, including opened insulin, eye drops, nasal spray, fiber powder, and control solutions without required open dates, expired floor stock meds, an uncapped insulin pen with dried blood, and a bag holding meds for three residents together. Staff interviews confirmed that expired meds should not remain on carts and that opened multi-dose products require dating, but the observed items were not stored or labeled in line with policy.
Improper Dating and Storage of Refrigerated Food: Surveyors found multiple refrigerated food items that were not sealed shut and lacked open dates, including lettuce and spinach, along with items labeled with dates indicating they were expired or should have been discarded. The RD, Culinary Director, and Administrator all confirmed that food packages should be dated when opened or marked with an X for expiration, and that expired food should not remain stored in the kitchen.
Staff failed to follow EBP and hand hygiene practices during resident care. An LPN and CNA provided care to a resident with a dialysis port without wearing gowns, an RN provided feeding tube and medication care to a resident with a feeding tube while not performing hand hygiene between tasks, and a CMT provided catheter and incontinence care to a resident with a urinary catheter without a gown and without changing gloves between dirty and clean tasks. The residents had conditions including dialysis dependence, feeding tube use, and urinary catheter use, and care plans required EBP for high-contact care.
A resident with multiple medical conditions who required staff assistance for transfers was not provided with a gait belt during a transfer, contrary to facility policy. After reporting dizziness, the resident was left unattended by a CNA who left to retrieve a gait belt, resulting in the resident falling and sustaining a hip fracture that required surgery. Staff and family interviews confirmed the resident was left alone, and the care plan lacked specific instructions for transfer assistance.
Two residents were affected by the facility's failure to ensure their rights to self-administer medications. One resident, with moderate cognitive impairment, was found with medications left at the bedside without an assessment or physician's order for self-administration. Another resident, with intact cognition, had medications removed from her locked bedside drawer despite having physician's orders to self-administer some of them. The facility's actions prevented the residents from exercising their rights to self-administer medications as assessed and ordered.
The facility failed to investigate an allegation of verbal abuse involving two residents. A resident reported that a nurse aide yelled at another resident, using derogatory language. Despite this, the facility did not document any investigation or interviews with involved parties. The Director of Nursing could not provide additional information or explain the lack of investigation. The only action taken was notifying the employment agency that the CNA was not allowed to return.
Two residents in an LTC facility experienced safety issues due to inadequate supervision and intervention. One resident, at risk for falls, fell twice within a week, sustaining injuries, with no effective interventions documented. Another resident, severely cognitively impaired, frequently wandered into other residents' rooms, including at night, without proper monitoring. Staff interviews revealed a lack of awareness and consistent implementation of safety measures, highlighting deficiencies in the facility's management of resident safety.
A facility failed to ensure an accurate MDS assessment for a resident with dementia and Alzheimer's, who was at high risk for wandering. Despite the resident's care plan and elopement risk assessment indicating wandering behavior, the MDS did not reflect this. Observations confirmed the resident's wandering, and interviews revealed that the Social Services Director did not document the behavior due to a lack of awareness and thorough questioning.
The facility failed to include end dates for PRN psychotropic medications for two residents, contrary to policy requirements. One resident frequently used alprazolam for anxiety without an end date, while another was prescribed hydroxyzine without an end date but did not use it. Staff interviews revealed confusion about the 14-day limit policy, and the DON noted potential risks like falls and oversedation due to this oversight.
A facility failed to maintain an accurate medical record for a resident, leading to a deficiency. The resident's record lacked an updated PASRR Level 1 form, and there was inconsistent documentation of a bipolar disorder diagnosis. The diagnosis was added and removed multiple times without clear confirmation from the attending physician or psychiatrist. This inconsistency was identified during a survey, revealing potential issues with the resident's mental health documentation.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional principles. Surveyors observed multiple medication storage problems affecting seven sampled residents, including an open insulin pen for one resident, opened multi-use eye drops and nasal spray without open dates for two residents, an uncapped pre-primed insulin pen with dried blood on it, and a clear storage bag containing medications for three different residents together. The report also identified an opened floor stock fiber powder without an open date, two expired floor stock oral medications, and four vials of blood sugar testing solutions that were expired based on the facility’s 90-day-after-opening requirement. The facility’s policy required opened medications to be dated, expired or contaminated medications to be removed from active supply and destroyed, and certain multi-dose products and testing solutions to have shortened expiration dates after opening. During observations on the medication carts, surveyors found Resident #10’s insulin pen opened with an open date, Resident #79’s eye drops and Resident #97’s Flonase without open dates, Resident #41’s insulin pen with a needle attached and dried blood on it stored with floor stock oral medications, and a bag containing medications for Residents #102, #46, and #50 together. Staff interviews indicated that expired medications should not remain on carts, that disposal containers were available on each floor, and that opened multi-dose medications were expected to be labeled, while the DON stated the bagged medications had been disposed of and that opened multi-dose vials were good for 28 days.
Improper Dating and Storage of Refrigerated Food
Penalty
Summary
Food was not stored in accordance with professional standards for food service safety when the facility failed to ensure food items were dated with an open date or expiration date and failed to dispose of expired food items. During observation of the walk-in refrigerator, surveyors found an open package of lettuce that was not sealed shut and had no open date, two packages of spinach that were not sealed shut and had no open dates, and an open package of shredded carrots with a use-by date of 3/16/26. A container of grapefruit had a manufacturer’s use-by date of 2/13/26 and a written open date of 2/10/26, and whipped cream cheese was labeled with an X 3/19. The Registered Dietician stated that an X next to the date meant the food expired on that date. On a later observation of the walk-in refrigerator, surveyors again found the container of grapefruit with the same dates and a bag of spinach that did not have an open date and was not sealed shut. Staff interviews confirmed that food packages should have a date showing when they were opened or an X indicating the expiration date, that items without dates had likely been forgotten, and that open packages of lettuce should have been sealed shut. The Culinary Director stated expired food should have been thrown away, and the Administrator stated food items from February 2026 should not still have been stored in the kitchen in April.
Failure to Use EBP and Maintain Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when staff did not use enhanced barrier precautions (EBP) and did not follow hand hygiene and glove-changing practices during resident care. The report states that EBP policy required gowns and gloves during high-contact care for residents with indwelling devices, chronic wounds, or certain infections, and that hand hygiene was required after contact with body fluids and after removing gloves. The deficiency affected three of 18 sampled residents in a census of 87. One resident was cognitively intact, incontinent of bowel and bladder, and dependent on dialysis with diagnoses including end stage kidney disease, diabetes, and high blood pressure. The resident’s care plan required EBP because of an indwelling dialysis port. During observation, an LPN performed an accucheck wearing only gloves, and later the resident was transferred with a mechanical lift by an LPN and CNA without either staff member wearing a gown. The CNA later provided incontinence care without a gown. In interview, the CNA and LPN acknowledged that a gown should have been worn for dialysis-related care, transfers, and incontinent care. A second resident had mild cognitive impairment, received 50% of calories via feeding tube, and had diagnoses including stroke, diabetes, high blood pressure, and non-Alzheimer’s dementia. The care plan required EBP because of the feeding tube and directed staff to apply gown and gloves before high-contact activities. During observation, an RN entered after using ABHR and applied gloves, attached the feeding tube, administered fluids and tube feeding, then removed gloves and left without hand hygiene before preparing medication. The RN returned without hand hygiene or gloves, administered oral medications, applied pain patches, and exited without hand hygiene. A third resident had severe cognitive impairment, frequent bowel incontinence, a urinary catheter, and diagnoses including high blood pressure, cognitive dysfunction, and neurogenic bladder. The care plan required EBP for the catheter and directed staff to wear gown and gloves for catheter and incontinence care. During observation, a CMT performed catheter and incontinence care without a gown and changed from dirty to clean tasks without changing gloves, while also turning off the call light with soiled gloves. The CMT and DON stated that gowns were required for peri/incontinence care, tube feeding administration, and catheter care, and that gloves and hand hygiene should be used between dirty and clean tasks.
Failure to Provide Adequate Supervision and Use Gait Belt Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when facility staff failed to provide adequate assistance and supervision to prevent accidents for a newly admitted resident with multiple medical conditions, including right lung cancer, hypertension, and a post-surgical wound. The resident was assessed as needing staff assistance with transfers using a gait belt and a second person for hygiene and equipment management. However, the resident's care plan did not specify transfer or ambulatory status, nor did it address the use of a walker or gait belt, or the level of staff assistance required for mobility. On the day of the incident, a CNA assisted the resident from bed to a standing position without applying a gait belt, despite being trained and facility policy requiring its use. The resident began ambulating toward the restroom and reported feeling dizzy. The CNA instructed the resident to hold onto the grab bar and left the resident unattended to retrieve a gait belt. While the CNA was away, the resident attempted to turn and sit on the toilet, lost balance, and fell, striking their head and sustaining a left hip fracture that required surgical intervention. Interviews with staff and a family member confirmed that the resident was left standing alone and that the fall could have been prevented if the resident had not been left unattended. Facility policies and staff interviews indicated that all staff are expected to use gait belts for transfers and ambulation and to remain with residents who require assistance. The failure to follow these protocols directly led to the resident's fall and injury.
Failure to Ensure Resident Rights for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents were able to exercise their rights regarding self-administration of medications. Resident 54, who was moderately cognitively impaired with a BIMS score of 12 out of 15, was found with a medication cup containing three pills on his overbed table. The resident was not assessed for the ability to self-administer medications, and there was no physician's order for self-administration. The Certified Medication Technician admitted to leaving the medications at the bedside, which was confirmed by the MDS Coordinator. The Director of Nursing and Clinical Manager acknowledged the incident, stating it should not have occurred. Resident 23, who had intact cognition with a BIMS score of 15 out of 15, desired to self-administer medications and was assessed as capable of doing so. Despite having physician's orders to self-administer certain medications, the facility staff removed medications from the resident's locked bedside drawer without her knowledge. The Clinical Manager removed an unlabeled bottle of Tums and other medications, citing a lack of physician's orders, although the resident had orders for some of the medications. The resident expressed frustration over the removal of her medications, which she had been using for a long time. Interviews with the resident, family member, and staff revealed discrepancies in the handling of the resident's medications. The Clinical Manager admitted to removing medications without the resident present and acknowledged the need for physician's orders for self-administration. The Licensed Practical Nurse confirmed that the resident self-administered her nebulizer and could have cough drops at bedside, but there was confusion over the administration of other medications. The facility's actions resulted in the residents being unable to exercise their rights to self-administer medications as assessed and ordered.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of verbal abuse by a staff member involving two residents. Resident 26, who was severely cognitively impaired with a BIMS score of six, and Resident 32, who was cognitively intact with a BIMS score of 13, were involved in the incident. Resident 32 reported during a Resident Council meeting that a nurse aide was yelling at Resident 26 and using derogatory language. Despite this report, the facility did not document any investigation into the allegation, including interviews with the involved parties or assessments of the residents. The facility's investigation documentation was incomplete, lacking notes from the Former Social Service Coordinator and any evidence of interviews with the alleged perpetrator or other residents. The Director of Nursing was unable to provide additional information or explain why the allegation was not investigated. The only action taken was notifying the employment agency that the identified CNA was not allowed to return to work at the facility. This lack of investigation and documentation created the potential for abuse of other residents.
Inadequate Supervision and Intervention for Resident Safety
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent falls for two residents, leading to multiple incidents. One resident, who was at risk for falls due to decreased cognition and medication use, experienced two falls within a week. The first fall occurred when the resident fell asleep while sitting on the edge of the bed, resulting in abrasions and hip pain. Despite this incident, no new interventions were documented in the resident's care plan. A week later, the resident fell again in a similar manner, sustaining additional injuries including a nosebleed and bruising. The facility's failure to identify a pattern in the falls and implement effective interventions contributed to these repeated incidents. Another resident, who was severely cognitively impaired and at high risk for elopement, was observed wandering throughout the unit and entering other residents' rooms. This behavior occurred frequently, including during the night when staffing levels were lower, increasing the risk of harm to herself and others. Despite the resident's care plan indicating the need for monitoring and interventions to address wandering, staff interviews revealed a lack of awareness and consistent implementation of these measures. The facility's inability to effectively manage the resident's wandering behavior and ensure her safety, as well as the safety of other residents, was a significant deficiency. Interviews with staff and residents highlighted the facility's inadequate response to these safety concerns. Staff were aware of the residents' behaviors but failed to implement or document effective interventions. The facility's policies on fall management and elopement risk were not adequately followed, resulting in repeated incidents and potential harm to residents. The lack of appropriate supervision and intervention for these residents demonstrated a failure to maintain a safe environment, as required by regulatory standards.
Inaccurate MDS Assessment for Resident with Wandering Behavior
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident, identified as R21, which had the potential to result in unmet care needs. R21 was admitted with diagnoses including dementia, anxiety disorder, major depressive disorder, and Alzheimer's disease. The resident's Elopement Risk assessment indicated a high risk of wandering, yet the quarterly and annual MDS assessments did not record wandering behavior. Observations showed R21 ambulating in the hallway and interacting with staff, which was consistent with wandering behavior. The care plan for R21 included interventions for wandering, such as monitoring the Wander Guard and providing diversions. Interviews revealed that the Social Services Director (SSD) was responsible for completing the behavioral and wandering section of the MDS but failed to document R21's wandering behavior. The SSD admitted to not being aware of the resident's wandering and acknowledged the need for more thorough questioning during team meetings. The Director of Nursing (DON) stated that the MDS assessment did not reflect wandering because it did not trigger during the look-back period. The DON expected staff to review progress notes, elopement risks, and care plans when completing assessments.
Failure to Include End Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to include an end date for PRN psychotropic medications for two residents, which is a requirement according to their policy. Resident 16 was admitted with a diagnosis of anxiety with depression and was prescribed alprazolam 0.5 mg PRN for anxiety upon discharge from the hospital. The order for this medication did not include an end date until nearly a month later. The facility's December SNF Review did not mention the alprazolam, and the resident reported frequent use of the medication at night. Similarly, Resident 282 was admitted with diagnoses including pneumonia and chronic respiratory failure and was prescribed hydroxyzine pamoate 50 mg PRN for anxiety, also without an end date. The facility's December SNF Review did not mention the hydroxyzine, and the resident reported not using the medication. Interviews with facility staff revealed a lack of understanding and adherence to the policy requiring a 14-day limit on PRN psychotropic medications. LPNs and the Infection Preventionist were uncertain about the regulatory requirements for end dates on these medications. The Director of Nursing expected nurses to enter a 14-day end date for PRN psychotropic medications, with the option for the doctor to renew or discontinue the order after this period. The absence of end dates for these medications had the potential for residents to receive them without ongoing assessment for continued appropriateness, which could lead to issues such as falls, oversedation, and polypharmacy, as noted by the DON.
Inaccurate Medical Record and PASRR Documentation for a Resident
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident, identified as R37, which led to a deficiency. The resident's medical record did not include an updated Preadmission Screening and Resident Review (PASRR) Level 1 form, and there was conflicting documentation regarding a diagnosis of bipolar disorder. The PASRR Level 1 form dated 02/16/21 did not document a serious mental illness, and as a result, a PASRR Level 2 screening was not triggered or completed. However, other parts of the medical record, such as the Physician Order Report and the Continuity of Care Document (CCD), inconsistently documented a diagnosis of bipolar disorder. The inconsistency in R37's medical record was further complicated by the fact that the diagnosis of bipolar disorder was added and removed multiple times without clear documentation or confirmation from the resident's attending physician or psychiatrist. The Director of Nursing (DON) was unsure how the bipolar diagnosis was added to the CCD/Face Sheet document, and the attending physician and psychiatrist did not document this diagnosis in their notes. The issue was brought to the attention of the DON during the survey, prompting a review by the psychiatry physician group, which led to the discontinuation of the bipolar diagnosis. Interviews with facility staff, including the Administrator and the DON, revealed that the bipolar diagnosis was first noted by a Nurse Practitioner on 03/11/21, and there was an additional PASRR Level 1 form that identified serious mental illness with a bipolar diagnosis, which had not been included in R37's electronic medical record. This oversight and the inconsistent documentation created a potential for the resident to experience stigma and for staff and medical providers to lack accurate information about the resident's mental health condition.
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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 Saint Joseph
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carriage Square Rehab And Healthcare Center | 1.5 mi | ★★★★★ | 7 | 0 |
| St Joseph Manor Health & Rehabilitation | 1.8 mi | ★★★★★ | 5 | 0 |
| Belleview Care Center | 1.8 mi | ★★★★★ | 2 | 0 |
| Advanced Care Of St Joseph | 3.7 mi | ★★★★★ | 1 | 0 |
| St Joseph Chateau | 4.1 mi | ★★★★★ | 0 | 0 |
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