Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 St Joe Manor during CMS and state inspections, most recent first.
Food was stored, prepared, distributed, and served under unsanitary conditions. Dietary staff were observed working without hair restraints or proper beard coverage, frozen pork loin was thawed in standing water in a sink, and multiple kitchen and dishwashing surfaces had grime, debris, dust, and damage. In the serving area, milk was found in a refrigerator at 58 F with repeated out-of-range temps documented on the log, while staff reported the room was hot and the refrigerator door was sometimes left open.
The facility failed to show evidence of an ongoing, effective, comprehensive, data-driven QAPI program focused on outcomes of care and QOL. Review showed the QAPI policy required monthly committee review, annual evaluation, and a current QAPI plan with goals, but the record showed no current QAPI plan or goals. The Administrator stated the plan had not been updated annually, that she was trying to improve PIPs with two open, and that the Medical Director was not usually present at quarterly meetings but was sent the minutes afterward.
A resident with severe cognitive impairment, dementia, schizophrenia, and stage four lung cancer had hospice and code status decisions documented without a legally authorized representative. The Administrator signed the hospice consent and DNR request, while the resident's record also showed a full code preference and a physician deposition stating a guardian should be appointed. Staff interviews indicated the resident lacked family involvement, guardianship was not completed, and the resident was not able to participate meaningfully in the consent process.
Failure to provide written transfer notices and bed-hold information: The facility did not document that written transfer/discharge notices or bed-hold policies with the daily rate amount were given to several residents or their representatives when residents were sent to the hospital, including emergency ER transfers. Facility leaders stated staff were expected to complete transfer/discharge notices for all hospital transfers and include the bed-hold rate amount, but the rate was not included on the bed-hold policy.
Failure to Obtain Catheter Orders and Follow G-Tube Orders: The facility did not obtain an order for a resident’s urinary catheter or catheter care, even though the care plan identified an indwelling catheter and a drainage bag was observed at the bedside. The facility also failed to follow a resident’s G-tube orders when an LPN did not verify placement by aspirating gastric contents, measuring tube length, or checking pH before giving Baclofen, water flushes, and enteral feeding; the resident had MS, gastrostomy status, malnutrition, and dysphagia.
A facility failed to complete and send dialysis communication forms with two residents on all dialysis days and failed to ensure one resident had a dialysis order. One resident with ESRD had forms missing on most dialysis trips and said staff did not check the shunt or do anything after dialysis, while another resident with ESRD and kidney involvement also had multiple missing forms despite orders for dialysis-related monitoring and for the nurse to complete the form and send it with the resident.
The facility failed to ensure two sampled CNAs received annual performance reviews. The employee handbook stated performance improvement would occur annually or as business needs dictate, but there was no policy for annual reviews and no documentation in either CNA's personnel file. The HR Director said the facility did not do performance reviews, while the Administrator and DON said they expected them at least every 12 months and confirmed they had not been completed for the two CNAs.
Staff failed to follow infection control practices during EBP care, incontinent care, medication administration, and glucometer disinfection. Two residents requiring EBP were cared for without the expected gown use, two residents received perineal care with repeated glove contamination and missed hand hygiene, and a CMT administered meds without hand hygiene while cleaning glucometers with the same wipe and without the required wet contact time.
Facility staff failed to regularly inspect bed frames, mattresses, and side rails for three residents with ordered side rails. Observations showed rails that moved with minimal effort, including a rail that was loose for a while and another resident who said the rail was broken. Interviews revealed the QA Nurse and Housekeeping Supervisor handled side rail checks and tightening, but some rails did not fit well and could become loose again.
Failure to post complete daily staffing information: The facility’s posted staffing sheet did not include the actual hours worked or total hours worked per shift for licensed and unlicensed staff, and it also omitted the daily census. Surveyors observed the incomplete posting on multiple occasions, and Employee J stated he/she had previously been told the actual and total hours did not need to be included. The Administrator and DON said the daily posting should include the total and actual hours worked per shift and the census.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers, as required by policy. This deficiency affected multiple residents, with no documentation of written notifications at the time of transfer. Interviews with staff revealed that the responsibility for sending transfer forms lies with floor nurses, but the expected notifications were not documented.
The facility failed to provide written information about the bed hold policy to residents and/or their representatives at the time of hospital transfer. This deficiency was noted for four residents, despite the facility's policy requiring such information to be given in writing. Interviews indicated that floor nurses were responsible for this task, but documentation was lacking.
The facility failed to accurately document MDS assessments for four residents, leading to discrepancies in recorded medical information. A resident's MDS inaccurately recorded insulin injections, while another's did not reflect hospice status. The facility lacked a policy on MDS accuracy, contributing to these errors, despite expectations from the MDS Coordinator and administration for accurate assessments.
The facility failed to implement comprehensive care plans for four residents, resulting in deficiencies in addressing their individual needs. A resident with paraplegia used side rails not included in their care plan. Another resident with sleep apnea used oxygen and a BIPAP machine, which were not documented. A third resident with COPD used oxygen therapy not reflected in their care plan. Lastly, a resident with chronic UTIs was on antibiotics, but their care plan did not address UTI management. The facility's policy requires care plans to be updated, but this was not followed.
The facility failed to update and revise care plans for several residents, leading to deficiencies in addressing individual needs. A resident's care plan did not address vape use, another was inaccurately listed as full code despite hospice care, and a third was not informed about care plan meetings. Additionally, a resident with multiple falls had outdated fall risk interventions, and another's care plan lacked bleeding precautions for an anticoagulant. The administration acknowledged the expectation for care plans to reflect current conditions.
Two residents in the facility did not receive consistent showers as per their scheduled ADLs, leading to extended periods without proper hygiene. One resident, with multiple health conditions, reported receiving showers only once every two weeks, while another resident with Parkinson's disease reported having only one shower a month. Staff interviews confirmed that residents should receive two showers per week, but records showed multiple missed opportunities.
A facility failed to obtain a physician's order for oxygen administration and did not ensure a BIPAP order included settings for a resident with multiple respiratory and cardiac conditions. The resident was observed using oxygen and a BIPAP machine without documented orders, and staff interviews confirmed the lack of necessary orders.
The facility failed to maintain a medication error rate below five percent, resulting in an 8.57% error rate due to improper insulin administration. Three residents were affected as insulin pens were not primed before use, contrary to manufacturer instructions. CMTs misunderstood the priming process, believing it was only necessary when the pen was first used. The ADON and DON confirmed the expectation to follow manufacturer's guidelines.
A facility failed to maintain proper infection control practices during foley catheter care for a resident. A CNA did not adhere to the facility's Handwashing/Hand Hygiene Policy and EBP policy, failing to perform hand hygiene between tasks and not wearing a gown as required. The CNA admitted to not knowing the location of gowns and acknowledged the need for hand hygiene. The facility's administration confirmed the expectation for staff to adhere to proper PPE use and hand hygiene protocols.
A facility failed to follow infection control practices during perineal care for a resident with a PICC line. Staff did not adhere to the Enhanced Barrier Precaution (EBP) policy, which required wearing gowns, gloves, and masks. Observations showed that CNAs did not wash hands before donning gloves or after removing them, and did not clean the area before placing a brief. Interviews revealed a lack of understanding of EBP requirements, and the administration acknowledged the failure to follow policy.
Facility staff failed to report a resident-to-resident abuse incident to the state licensing agency. A resident pushed another, causing a fall and head injury requiring staples. The DON did not report the incident, believing it unnecessary unless harm occurred, despite the facility's policy requiring such reports. The Administrator expected the incident to be reported, highlighting a protocol discrepancy.
Food Storage, Preparation, and Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served under sanitary conditions. During observation, three dietary staff worked in food preparation areas without hair restraints, and Dietary Aide S placed assorted deli style meats in storage bags without a hair restraint. In the serving area, Dietary Aide T loaded plates onto food trays without a proper restraint for facial hair, and Dietary Aide U scooped food from the steam table onto plates without a hair restraint. The facility policy required hairnets, hair restraints, and beard guards to be worn by dining services employees. Food handling practices also included unsafe thawing of frozen meat. Seven approximately 10-pound plastic packages of pork loin were observed thawed partially submerged in standing water in the three-compartment sink in the food prep area. The Dietary Supervisor stated the pork should have been placed in the walk-in refrigerator the night before but was not, and it thawed in the sink while the sink was plugged and filled with water. The facility policy stated that foods should never be thawed on a counter or at room temperature, and if refrigerator temperatures were outside the acceptable range, food should be transferred or discarded. The kitchen and serving areas showed multiple sanitation and maintenance problems. The commercial dishwasher, gas range, ice machine, can opener, floors, drains, walls, ceiling diffusers, and other surfaces had grime, debris, dust, oily film, or damage, including missing tiles, damaged wallboard, and peeled wall sections. In the serving area, a milk container was observed at 45 F in a refrigerator that measured 58 F, and the area room temperature was 83 F. The refrigerator temperature log showed repeated temperatures above the acceptable range throughout May, and staff stated the room was hot, the refrigerator door was sometimes left open, and the air conditioning vents were not working.
Lack of Current QAPI Plan and Ongoing QAPI Oversight
Penalty
Summary
The facility failed to demonstrate evidence of maintaining an ongoing, effective, comprehensive, data-driven QAPI program focused on indicators of outcomes of care and quality of life. Review of the facility’s QAPI policy showed that the program was to be facility-wide, data-driven, and overseen by the governing board, administrator, and QAPI committee, with monthly meetings to review reports, evaluate data, and monitor QAPI-related activities. The policy also stated that the QAPI plan should describe the process for identifying and correcting quality deficiencies, including tracking and measuring performance, setting goals and thresholds, identifying and prioritizing deficiencies, analyzing underlying causes, implementing corrective actions, and monitoring effectiveness. Record review of the facility’s 2020 QAPI Plan showed that annual evaluation of the plan was expected and that the QAPI Committee was to complete an annual plan identifying opportunities for improvement, but the record also showed there was no current QAPI Plan or goals. During interview, the Administrator stated she had not updated the QAPI Plan annually and said she was trying to do better with the PIPs, with two open at the time. She also stated the Medical Director was not usually at quarterly meetings and was instead sent the meeting minutes afterward, with occasional comments. In a later interview, the Administrator said she would expect the facility to have a current QAPI Plan.
Unauthorized Signing of Hospice and Code Status Documents
Penalty
Summary
The facility failed to ensure that treatment decisions, including hospice election and code status decisions, were made by the resident or a legally authorized representative for one sampled resident. Resident #7 had diagnoses including moderate protein calorie malnutrition, hypertension, mood affective disorder, Alzheimer's disease, major depressive disorder, schizophrenia, and dementia with mood disturbance. The resident's care plan documented impaired cognition, disorganized thinking, inattention, delusions, no family involvement, hospice care for stage four lung cancer, and a preference to remain full code. The MDS showed severely impaired cognition, and the resident's emergency healthcare directive recorded a verbal response to remain full code. The record also showed a hospice informed consent electing hospice care and a DNR request, both signed by the Administrator. A notarized written deposition stated the resident's physician believed a guardian should be appointed to protect the resident's person and/or manage property. During observation, the resident was lying in bed with eyes open and did not respond when spoken to. The SSD stated staff had been instructed to obtain a written deposition to appoint a guardian, but after learning the facility would have to pay for it, this was not followed through with. During interviews, the Administrator said she acted as the resident's representative after discussing the resident's condition with the physician, hospital, and interdisciplinary team, and signed the hospice and code status forms. The ADON stated residents with severely impaired cognition should not sign consent forms and that a responsible party, guardian, or another person should make decisions if no next responsible party existed. The DON said the hospital ethics committee told the Administrator she could sign for hospice care, while the physician stated he would typically expect the resident, guardian, or POA to sign documents and was not aware the guardianship was not followed through. The hospice office administrator said the DNR request arrived already signed, and the hospital patient safety and quality specialist said they did not tell the facility the Administrator could sign on the resident's behalf.
Failure to Provide Written Transfer Notice and Bed-Hold Information
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of transfers to the hospital and failed to provide a copy of the bed-hold policy with the daily rate amount upon transfer for six sampled residents. The cited residents were transferred to the hospital and later returned to the facility, including some same-day emergency transfers and others with hospital stays before returning. For each of these residents, the record review found no documentation that the written transfer notice or the bed-hold policy with the daily rate amount was provided at the time of transfer. The facility policy titled, Bed Holds and Returns, required residents and/or representatives to receive written information about bed-hold policies in advance and again at the time of transfer, or within 24 hours for an emergency transfer. The policy also required the written notice to explain the duration of any state bed-hold period, the reserve bed payment policy, the facility policy regarding bed-hold periods, the per-diem rate required to hold a bed, and the return policy. The policy titled, Transfer or Discharge, Facility-Initiated, also required written notice of the reason for transfer, effective date, location, appeal rights, ombudsman contact information, and the notice of facility bed-hold and return policies. During interview, the DON stated staff were supposed to complete a progress note when a resident went to the hospital, notify the family, give the bed-hold policy, and complete the transfer/discharge notice for everyone who went out, including ER visits. The Administrator, DON, ADON, and Social Services Director stated they would expect written notification of transfers to be completed with transfers and discharges, including ER visits, and that the bed-hold rate amount should be included. They also stated the private pay rate was not included on the bed-hold policy, although it was included on the admission paperwork.
Failure to Obtain Catheter Orders and Follow G-Tube Orders
Penalty
Summary
The facility failed to follow professional standards of quality by not obtaining an order for a urinary catheter for one resident and by not following physician orders for another resident with a G-tube. The report states the facility also did not provide a policy regarding G-tube orders. The facility policy for urinary catheter care required emptying the collection bag at least every eight hours, reviewing and documenting the clinical indications for catheter use before insertion, assessing and documenting the ongoing need for the catheter, and removing it as soon as it was no longer needed. For the resident with a G-tube, the medical record showed diagnoses of MS, gastrostomy status, protein calorie malnutrition, and dysphagia, with orders for NPO status, G-tube placement checks four times daily before use, Baclofen via G-tube, Jevity 1.5 tube feeding, and water flushes. During observation, an LPN did not obtain gastric contents during aspiration, did not measure the tube length, and did not check pH before giving Baclofen, a water flush, or enteral feeding. For the resident with a urinary catheter, the record showed no order for the catheter or catheter care, yet the care plan identified an indwelling urinary catheter and observation showed a drainage bag hanging at the bedside. Staff and leadership stated residents with catheters should have orders for the catheter and catheter care, and the RN said if no order was available the physician would be contacted and the catheter would be discontinued or an order and diagnosis obtained.
Incomplete Dialysis Communication and Missing Dialysis Order
Penalty
Summary
The facility failed to ensure dialysis communication forms were completed and sent with two residents on all dialysis days, and failed to ensure one resident had an order for dialysis. The facility policy stated that anyone going to dialysis must bring a dialysis communication form with the most recent vital signs or order changes, that the form should return with the resident after dialysis with any concerns or instructions from the dialysis center, and that any patient on dialysis must have a dialysis order and treatment orders to check the shunt or ports. One resident had ESRD, muscle weakness, and dependence on renal dialysis, with a physician order to send Velphoro to dialysis on Monday, Wednesday, and Friday, but no other dialysis-related orders. The resident's dialysis communication forms were not completed for 56 of 58 opportunities, and progress notes showed dialysis was canceled once and missed once. The resident stated staff did not check the shunt and did nothing when the resident returned from dialysis, and an LPN said the form was not completed that morning because he/she was late, although it should have been completed and sent with the resident. Another resident had ESRD, granulomatosis with polyangiitis with kidney involvement, and dependence on renal dialysis, with orders for dialysis-related monitoring and for the nurse to fill out the dialysis communication form and send it with the resident. That resident's forms were not completed for 13 of 32 opportunities, and staff stated they were unsure why the forms were missing or incomplete. The Administrator, DON, and ADON stated they would expect the dialysis communication forms to be completed on every dialysis day and for a resident receiving dialysis to have orders for dialysis.
Missing Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure two of three sampled Certified Nurse Aides (CNAs) received an annual performance review. Review of the employee handbook dated 12/08/23 showed the facility stated it would periodically review work performance and that the performance improvement process would take place annually or as business needs dictate, but the facility did not provide a policy related to annual performance reviews. Review of CNA K's personnel file showed a hire date of 04/09/25 with no documentation of an annual performance review, and review of CNA L's personnel file showed a hire date of 05/08/25 with no documentation of an annual performance review. During interview, the Human Resources Director said the facility did not do performance reviews and only added write-ups to the record if there was one. The Administrator and DON said they would expect performance reviews for nurse aides to be completed at least once every 12 months, and the DON later confirmed that performance reviews had not been completed for CNA K or CNA L.
Infection Control Failures During EBP, Incontinent Care, and Medication Pass
Penalty
Summary
The facility failed to follow enhanced barrier precautions for two residents who required them. One resident had a g-tube and EBP signage was posted on the door, but an LPN entered the room, performed medication administration and tube feeding tasks, and did not put on a gown for EBP. Another resident with a urinary catheter was provided catheter care by two CNAs who did not use a gown, and one CNA leaned over the resident and touched the resident with clothing while tucking the lift pad under the resident. During the catheter care, the CNA did not use disinfectant wash or soap to disinfect the catheter during cleaning, used washcloths to clean fecal material from the resident’s back peri area, and the staff did not change gloves or perform hand hygiene before applying a clean brief. The facility also failed to follow infection control practices during incontinent care for two residents. During perineal care for one resident, two nursing assistants entered the room and put on gloves without washing hands, handled soiled briefs and washcloths, and used the same soiled gloves to move between dirty and clean tasks. They touched clean linens, the bed controller, the call light, and other resident care items with contaminated gloves after contact with urine and fecal material, and then removed gloves and left without washing or sanitizing hands. During perineal care for another resident, one CNA washed hands in the restroom but then left the room to get supplies, returned and put on clean gloves without hand hygiene, and both staff used soiled gloves while cleaning the resident, touching the resident’s back and buttocks and handling dirty pads and linens before leaving the room. The facility further failed to provide appropriate infection control during medication pass and glucometer cleaning for three residents. A CMT did not perform hand hygiene before administering medications, handled two glucometers without a barrier, and wiped both devices with the same disinfecting wipe without keeping them wet for the required four-minute contact time before returning them to service. The same CMT also did not perform hand hygiene before medication administration for two other residents and did not perform hand hygiene after administering medications. The CMT and other staff involved stated they should have washed or sanitized hands before and after medication administration and that glucometers should be disinfected per the wipe manufacturer’s directions.
Loose and Broken Bed Side Rails Not Properly Inspected
Penalty
Summary
Facility staff failed to conduct regular inspections of bed frames, mattresses, and side rails as part of the maintenance program for three residents who had side rails in use. The facility policy required the interdisciplinary team to evaluate the sleeping environment, check bed frames, mattresses, and bed rails for compatibility and size before use, and have maintenance routinely inspect beds and related equipment for risks and problems, including entrapment risks. The policy also stated that worn or malfunctioning bed system components were to be repaired or replaced and that bed rails were to be properly installed and used according to manufacturer instructions. Resident #52 had an order for bilateral quarter upper side rails for repositioning and transfers, along with a signed side rail consent, bed rail measurement assessment, side rail resident assessment, and care plan addressing side rail use. During observation, the resident used the right side rail to help stand, and the rail moved with minimal effort. The resident stated the right rail had been loose for a while and used the rails to help with transfers from the bed and chair. Resident #96 had an order for a right upper quarter side rail for repositioning and transfers, with consent, measurement assessment, resident assessment, and care plan documentation in place. Observations showed the rail up while the resident was in bed and later while the resident was out of the room, and the rail could be moved with minimal effort. Resident #154 had an order for bilateral upper quarter side rails for repositioning and transfers, with consent, measurement assessment, resident assessment, and care plan documentation. During observation, the resident grabbed the bed rail during peri-care, and the rail moved with minimal effort and tilted inward. The resident stated the right side rail was broken and said he/she used the bed rails to help turn in bed and during care. Staff interviews showed the QA Nurse and Housekeeping Supervisor handled side rail assessments and tightening, but some rails did not fit well and could become loose again.
Failure to Post Complete Daily Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information with the actual hours and total hours worked per shift for licensed and unlicensed staff responsible for resident care, and it also failed to include the daily census on four observed days. The facility census was 147. Surveyors observed the staffing sheet taped to the window between the 500 and 600 Halls on 05/17/26 at 4:37 P.M., 05/18/26 at 3:00 P.M., 05/19/26 at 7:30 A.M., and 05/20/26 at 8:45 A.M., and each time the posted staffing data did not include the actual and total hours worked per shift for licensed and unlicensed staff or the census. Review of the facility policy titled, Posting Direct Care Daily Staffing Numbers, revised August 2022, stated that the daily posting should include the resident census, the shift for which the information is posted, the type and category of nursing staff working during that shift, the actual time worked during that shift for each category and type of nursing staff, and the total number of licensed and non-licensed nursing staff working for the posted shift. During interview, Employee J said he/she made and posted the daily staffing data sheets and that they should probably have the total and actual hours worked per shift and the daily census, but he/she had previously been told there was no need to include the actual and total hours worked. The Administrator and DON later stated they would expect the posting to include the total and actual hours worked per shift for licensed and unlicensed staff and the census.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives in writing of transfers or discharges to a hospital, including the reasons for such transfers, for eleven residents out of 28 sampled and one additional resident outside the sample. This deficiency was identified through interviews and record reviews, revealing a lack of documentation that the residents' representatives were informed in writing at the time of transfer. The facility's policy, revised in October 2022, mandates written notification to residents and their representatives, including specific details about the transfer or discharge, the effective date, and the new location. The policy also requires that a copy of the notice be sent to the Office of the State Long-Term Care Ombudsman. However, the review showed that for multiple residents, including those who were transferred to the hospital on various dates, there was no documentation of written notification to the residents' representatives. The facility's policy considers transfers to acute care settings as facility-initiated transfers, not discharges, and expects residents to return to the facility. Despite this, the required notifications were not documented. Interviews with facility staff, including the Social Services Designee and Registered Nurse, indicated that the responsibility for sending out transfer forms lies with the floor nurses. The Administrator, Director of Nursing, and Assistant Director of Nursing acknowledged the expectation that residents and their representatives should be notified in writing of transfers. The lack of documentation for these notifications constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
The facility failed to provide written information to residents and/or their representatives regarding the facility's bed hold policy at the time of transfer to the hospital. This deficiency was identified for four residents out of a sample of 28, despite the facility's policy requiring that such information be provided in writing at least twice: in advance of any transfer and at the time of transfer. The policy, revised in October 2022, mandates that residents and their representatives be informed of the bed hold policies, which address holding or reserving a resident's bed during periods of absence, such as hospitalization or therapeutic leave. Interviews with facility staff revealed that the responsibility for sending out the bed hold policies lies with the floor nurses at the time of resident discharge. However, there was no documentation in the medical records of the four residents indicating that they or their representatives were informed in writing of the bed hold policy at the time of their transfers to the hospital. The facility's administration, including the Administrator, Director of Nursing, and Assistant Director of Nursing, collectively acknowledged the expectation that residents and/or their representatives should be made aware of bed holds in writing.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to document accurate Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in the recorded medical information. Resident #40's medical record indicated that they received an injection of Ozempic but did not receive insulin during the seven-day look-back period. However, the MDS assessment inaccurately recorded that the resident received one insulin injection. Similarly, Resident #41's record showed an injection of Ozempic without any insulin received, yet the MDS assessment incorrectly noted one insulin injection. Resident #131's medical record documented two Haldol injections, but the MDS assessment marked zero injections received in the look-back period. Lastly, Resident #138, who was admitted to hospice, had an MDS assessment that inaccurately marked 'no' for a condition that may result in a life expectancy of less than six months. The facility did not provide a policy regarding MDS accuracy, which may have contributed to these inaccuracies. Interviews with the MDS Coordinator and the facility's administration, including the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), revealed an expectation for MDS assessments to accurately reflect the residents' conditions at the time of assessment. Despite this expectation, the discrepancies in the MDS documentation for these residents indicate a failure to meet this standard, as evidenced by the inaccurate coding of injections and hospice status.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plans with specific interventions for four residents, leading to deficiencies in meeting their individual needs. Resident #31, who has diagnoses including paraplegia and rheumatoid arthritis, was observed using side rails for mobility, yet their care plan did not address the use of side rails. This oversight indicates a lack of alignment between the resident's needs and the documented care plan. Resident #41, diagnosed with obstructive sleep apnea and other respiratory conditions, was observed using oxygen and a BIPAP machine, but their care plan did not include these critical interventions. Similarly, Resident #55, with COPD and atrial fibrillation, was using oxygen therapy, which was not reflected in their care plan. These omissions suggest a failure to update care plans to reflect the residents' current medical needs and prescribed treatments. Resident #111, who has a history of chronic UTIs and other health issues, was taking antibiotics for a UTI, yet their care plan did not address the management of chronic UTIs. The facility's policy requires care plans to be updated with measurable objectives and time frames, but these were not adhered to, as evidenced by the lack of updates in response to significant changes in the residents' conditions. The facility's administration acknowledged the expectation for care plans to be current and reflective of residents' conditions.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans with specific interventions to meet the individual needs of five residents. Resident #1's care plan did not address the use of vapes, despite observations of the resident having a vape in their room and on their lap. Additionally, the resident reported not taking any medications, yet the care plan included several medication-related interventions. Resident #6's care plan inaccurately listed the resident as a full code, despite an order for hospice care and a DNR status. Resident #18 was not informed about upcoming care plan meetings, and there was no documentation to indicate that the resident was notified, despite expressing a desire to attend these meetings. Resident #34 experienced twelve unwitnessed falls, including falls with injuries, but the care plan's fall risk interventions had not been updated since August 2023. This lack of updated interventions occurred despite a significant change in the resident's condition, as indicated by a recent MDS assessment. Resident #126's care plan failed to address bleeding precautions and interactions related to the prescribed anticoagulant, Apixaban. Additionally, the care plan did not address the resident's use of marijuana, despite noting the resident's unsupervised smoking and vaping habits. The facility's administration acknowledged the expectation for care plans to reflect the current condition of residents, which was not met in these cases.
Inconsistent Shower Schedule for Residents
Penalty
Summary
The facility failed to provide consistent care for activities of daily living (ADLs) for two residents, resulting in extended periods without showers. Resident #24, who has multiple health conditions including arthritis, spinal stenosis, COPD, diabetes, heart failure, morbid obesity, and severe chronic kidney disease, reported receiving showers only once every two weeks despite being scheduled for twice a week. The resident expressed feeling dirty and uncomfortable with facial hair due to the infrequent showers. Records showed that in December 2024, the resident missed six out of nine scheduled showers, and in January 2025, missed another six out of nine. Similarly, Resident #55, diagnosed with Parkinson's disease, COPD, heart failure, and other conditions, reported having only one shower a month, despite being scheduled for two per week. The resident expressed concern about personal hygiene and odor. Records indicated that in December 2024, the resident missed seven out of nine scheduled showers, and in January 2025, missed eight out of nine. Interviews with staff, including a CNA, RN, ADON, and DON, confirmed that residents should receive two showers per week, but the facility failed to adhere to this schedule consistently.
Failure to Obtain Orders for Oxygen and BIPAP Settings
Penalty
Summary
The facility failed to obtain a physician's order for oxygen administration and did not ensure that a physician's order for bilevel positive airway pressure (BIPAP) included the necessary settings for a resident. This deficiency affected one resident who had multiple diagnoses, including obstructive sleep apnea, shortness of breath, respiratory failure, chronic kidney disease, heart failure, and chronic obstructive pulmonary disease. The resident was observed using oxygen via nasal cannula at 3.5 liters per minute and had a BIPAP machine at bedside, but there were no documented orders for the oxygen or the BIPAP settings. Interviews with the resident and facility staff, including a Licensed Practical Nurse (LPN), a Registered Nurse (RN), the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, confirmed the lack of necessary orders. The resident reported regular use of oxygen and BIPAP at bedtime, while the staff acknowledged that orders for oxygen and BIPAP settings should be in place. The facility's policy required a review of the physician's order for BIPAP settings, but this was not followed, leading to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration, resulting in an error rate of 8.57%. This deficiency affected three residents out of seven sampled. The errors were related to the improper administration of insulin using pen-type devices, specifically the failure to prime the insulin pens before administration, as required by the manufacturer's instructions. This oversight was observed in the administration of both NovoLog and Insulin Lispro to the residents. Resident #32 received three units of NovoLog without the pen being primed, despite a blood sugar level of 204. Similarly, Resident #102 was administered six units of Insulin Lispro without priming the pen for a blood sugar level of 236. Resident #133 also received three units of Insulin Lispro without the pen being primed. Interviews with the Certified Medication Technicians (CMTs) involved revealed a misunderstanding of the priming process, as they believed priming was only necessary when the pen was first used. The Assistant Director of Nursing and the Director of Nursing confirmed that staff are expected to follow the manufacturer's guidelines for insulin administration.
Infection Control Deficiency in Foley Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices and implement Enhanced Barrier Protections (EBP) during foley catheter care for a resident. The facility's Handwashing/Hand Hygiene Policy and EBP policy were not adhered to by a Certified Nursing Aide (CNA) during the care of a resident with a foley catheter. The CNA did not wash or sanitize hands before donning gloves, did not wear a gown as required by EBP, and failed to perform hand hygiene between dirty and clean tasks and before leaving the resident's room. During the observation, the CNA was seen entering the resident's room, donning gloves without prior hand hygiene, and not wearing a gown despite EBP signage and supplies being accessible. The CNA performed catheter care and peri care without proper hand hygiene between tasks and left the room with trash without sanitizing hands. The CNA admitted to not knowing the location of gowns and acknowledged the need for hand hygiene between tasks and before leaving the room. The facility's administration confirmed the expectation for staff to adhere to proper PPE use and hand hygiene protocols.
Infection Control Deficiency During Perineal Care
Penalty
Summary
The facility failed to maintain proper infection control practices during perineal care for a resident with a Peripherally Inserted Central Catheter (PICC). The facility's Perineal Care Policy and Enhanced Barrier Precaution (EBP) Policy were not followed. During an observation, it was noted that a Certified Nursing Aide (CNA) donned gloves without washing hands and performed perineal care without cleaning the area first. Additionally, the CNA did not wash hands after removing gloves and before leaving the room. The EBP signage on the resident's door indicated the need for protective gear, but the staff did not adhere to these guidelines. Interviews with the staff revealed a lack of understanding and adherence to the EBP policy. CNA A and CNA B did not wear the required gown, gloves, and mask during care for the resident with a PICC line, despite the policy indicating that EBP should be used for residents with such devices. The Licensed Practical Nurse (LPN) confirmed that EBP should be worn for residents with medical devices like a PICC line. The resident also reported that staff had not been wearing gowns during care, only masks and gloves during PICC line care. The facility's administration acknowledged that the staff should have followed the policy and washed hands between dirty and clean tasks.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility staff failed to report an incident of resident-to-resident abuse to the state licensing agency as required. The incident involved two residents, where one resident pushed another, resulting in a fall that caused a head injury requiring two staples and a skin tear on the elbow. The facility's policy mandates reporting such incidents to the state agency, but this was not done. The Director of Nursing (DON) was informed by the state licensing agency that reporting was not necessary unless harm occurred, which led to the decision not to report the incident. The incident occurred when one resident accused another of stealing food and pushed them, causing the fall. The facility's investigation noted the fall was unwitnessed and did not initially observe injuries on the resident who fell. However, the resident was later transferred to the hospital due to the injuries sustained. The Administrator expressed that such incidents should be reported to the state licensing agency, indicating a discrepancy between the facility's actions and the expected protocol.
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 80 citations issued within 25 miles in the last 12 months — including the 1 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 Bonne Terre
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Desloge | 4 mi | ★★★★★ | 0 | 0 |
| Country Meadows | 4.7 mi | ★★★★★ | 1 | 0 |
| Community Manor | 10.6 mi | ★★★★★ | 2 | 0 |
| Camelot Nursing And Rehabilitation Center | 10.9 mi | ★★★★★ | 7 | 0 |
| Southbrook Nursing Center | 11.1 mi | ★★★★★ | 4 | 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 August 2026) and official state health department websites.