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 St Joseph Manor Health & Rehabilitation during CMS and state inspections, most recent first.
Failure to prevent resident-to-resident physical abuse led to injuries in two separate altercations. In one event, two residents argued in the dining room, then one scratched the other’s neck and was hit in the face, leaving scratches, redness, and swelling. In another event, a resident pushed another resident’s plate to the floor, the other resident struck back with a reacher, and the first resident dug fingernails into the other resident’s hand, causing cuts. Both incidents involved residents with significant cognitive, psychiatric, and neurologic diagnoses.
A resident with a supra pubic catheter repeatedly requested to have their urinary collection bag changed from a leg bag to a bedside gravity drainage bag at night, but staff did not honor this request. The care plan and physician's orders did not specify the resident's preferences or address the use of different collection bags, resulting in the resident experiencing urinary leakage, a saturated bed, and distress. Nursing staff and leadership acknowledged the oversight, and observations confirmed the resident's needs were not met.
The facility did not employ a full-time RD or a qualified DM to oversee food and nutrition services, with the current DM lacking required certification and experience, and the RD only providing monthly consulting. This affected nearly all residents receiving meals from the kitchen.
Staff failed to follow infection prevention protocols in several areas, including improper disinfection of a glucometer between two residents, not wearing required gowns while sorting soiled linens, and not donning full PPE when entering a COVID isolation room or providing care to a resident on Enhanced Barrier Precautions. These actions were inconsistent with facility policies and placed all residents at risk for infection transmission.
Multiple residents were inaccurately coded in the MDS regarding the use of restraints, falls, and UTI documentation. Devices such as side rails and enabler bars were incorrectly coded as physical restraints, even though they did not restrict resident mobility. Several falls and a UTI were not properly documented in the MDS, despite clear evidence in the medical records. These errors were attributed to misunderstandings of coding definitions, lack of training, and absence of audit processes.
A resident with major depressive disorder and PTSD was not provided with required mental health services or a behavioral support plan as indicated by the PASRR Level II evaluation. The Social Services Director did not review the PASRR recommendations, inaccurately completed trauma screenings, and failed to arrange psychiatric consultation or develop a care plan addressing PTSD, resulting in unmet mental health needs.
A resident was prescribed and administered antibiotics for a UTI without timely completion of an infection screening evaluation by the Infection Preventionist, as required by the facility's antibiotic stewardship policy. The IP was not informed of the resident's UTI status upon return from the ER and did not review the orders, resulting in a delay in completing the infection worksheet and evaluating the appropriateness of the prescribed antibiotic.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to keep residents free from resident-to-resident physical abuse when two separate altercations occurred involving four residents. In one incident, Resident #1, who had diagnoses including dementia, major depressive disorder, and mood disorder, and Resident #2, who had diagnoses including COPD, bipolar disorder, cerebral infarction, and major depressive disorder, became involved in a verbal confrontation in the dining room after Resident #1 told another resident that he or she could leave the facility if unhappy there. Resident #2 approached Resident #1 to object, the exchange escalated, Resident #2 scratched Resident #1 on the neck, and Resident #1 hit Resident #2 in the face. Resident #1 had three scratches on the neck, and Resident #2 had redness and swelling to the right cheek. In a separate incident, Resident #3 and Resident #4 became involved in an altercation in the small dining room. Resident #3 had diagnoses including cerebral infarction with left-sided hemiplegia/hemiparesis, dysphagia, traumatic brain injury history, anxiety disorder, schizoaffective disorder, and major depressive disorder. Resident #4 had diagnoses including Parkinson's disease, cerebral infarction, cognitive communication deficit, restlessness and agitation, and major depressive disorder. The investigation stated that Resident #3 rolled up to Resident #4's table and pushed Resident #4's plate to the floor. Resident #4 stood up, grabbed Resident #3's reacher, and hit Resident #3 in the thigh several times. Resident #3 then grabbed Resident #4's hand and dug fingernails into the top of the hand, causing cuts, and Resident #4 threw a drink on Resident #3 before staff separated them. The report also states that Resident #3 had previously been upset about being sprayed with a hose by Resident #4 outside the facility, and Resident #3 later said he or she was still angry about that event. Both residents in the second incident were interviewed and described the altercation, and Resident #4 reported that the residents ate in different dining rooms afterward. The facility investigation documented that staff educated the residents on appropriate behavior and that staff received abuse and neglect education, but the deficiency was based on the occurrence of the resident-to-resident physical abuse and the injuries that resulted.
Failure to Honor Resident's Catheter Care Preferences and Self-Determination
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not accommodating the resident's repeated requests to have their urinary catheter bag changed from a leg bag to a bedside gravity drainage bag at night. Despite being alert, oriented, and able to communicate needs, the resident was left with a leg bag overnight, resulting in urinary leakage, a saturated bed, and significant distress. The care plan did not address the resident's new supra pubic catheter or specify the resident's preferences for catheter care, such as the use of different collection bags during the day and night. Additionally, the physician's orders did not specify the type of collection bag to be used at different times, and there was no documentation that the catheter and collection bag had been changed as ordered for the month. Interviews with nursing staff confirmed that the resident had requested the change to a bedside bag weeks prior, but the request was not fulfilled. Observations showed the resident was visibly upset and that no bedside gravity drainage bag was present in the room. Both LPNs and facility leadership acknowledged that residents with urinary catheters should have their collection bags changed to a bedside bag when lying down, and that the resident's rights and requests should have been honored. The failure to address the resident's needs led to loss of dignity and mental anguish for the resident.
Failure to Employ Qualified Dietary Leadership
Penalty
Summary
The facility failed to employ either a full-time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to oversee the food and nutrition service since August 2024. Review of the facility's job description for the DM position indicated a preference for completion of an approved dietary manager's course and experience in a supervisory capacity, but the current DM, who began as a temporary employee in October 2024 and became full-time in February 2025, did not have prior experience as a DM, was not a Certified Dietary Manager (CDM), and was not enrolled in a CDM course. The DM confirmed this lack of qualifications during an interview. Additionally, the RD was not employed full-time and only provided consulting services once a month for eight hours, offering clinical coverage for the resident population. The facility administrator confirmed that there had not been a CDM since August 2024, and the current DM was not a CDM. This deficiency had the potential to affect 55 residents who received food from the kitchen, with the facility census at 56.
Multiple Failures in Infection Prevention and Control Practices
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program in several key areas. During blood glucose monitoring, an LPN used Clorox wipes to clean a multi-use glucometer between residents, contrary to the manufacturer's instructions, which require an EPA-registered disinfectant or a specific bleach solution. The Infection Preventionist was unaware of the bloodborne pathogen status of residents and provided inconsistent guidance regarding appropriate disinfection. Facility policy requires cleaning and disinfecting reusable items according to CDC recommendations and OSHA standards, but this was not followed in practice. In the laundry area, staff did not consistently wear gowns when sorting soiled linens and personal clothing, only donning them when items were in biohazard or COVID-marked bags. Both the Housekeeping Director and a Laundry Aide confirmed this practice, which was inconsistent with facility policy mandating gown and glove use for all soiled linen sorting. The Infection Preventionist had not yet assessed the laundry area for infection control compliance, and the Administrator expected staff to follow the policy to prevent infection transmission. Staff also failed to use proper PPE when entering a resident's room on airborne precautions for COVID, with a CNA entering the room wearing only a surgical mask despite signage and policy requiring a gown, gloves, N95 mask, and eye protection. Additionally, an LPN did not wear a gown while administering medications via a gastrostomy tube to a resident on Enhanced Barrier Precautions, despite clear signage and available PPE. These lapses were confirmed by staff interviews and were not in accordance with facility policies or posted instructions.
Inaccurate MDS Coding for Restraints, Falls, and UTI Documentation
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for multiple residents, resulting in deficiencies related to restraints, fall assessments, and urinary tract infection (UTI) documentation. Specifically, seven residents were incorrectly coded as having physical restraints due to the use of side rails or enabler bars, which, according to observations and interviews, did not impede the residents' mobility or ability to exit the bed. The MDS Coordinator admitted to coding these devices as restraints out of caution, despite the devices not meeting the Centers for Medicare and Medicaid Services (CMS) definition of a physical restraint. The MDS consultant also acknowledged a misunderstanding of the restraint definition and confirmed that no training or audits had been conducted to ensure accurate MDS coding. Additionally, the facility failed to accurately document falls for three residents. In each case, the residents experienced falls, some resulting in injury, but these incidents were not properly coded in the subsequent MDS assessments. Interviews with the MDS Coordinator revealed that these omissions were due to oversight during the MDS completion process, and there was no evidence of a review or audit process by the facility's MDS consultant company to catch such errors. The facility also failed to accurately code a UTI for one resident. Despite clear documentation in the medical record, including physician orders for antibiotics and hospital discharge lab results confirming a UTI, the MDS did not reflect that the resident had experienced a UTI in the last 30 days. The MDS Coordinator stated that the omission was due to not finding the relevant lab results in the hospital discharge report at the time of MDS completion. These inaccuracies in MDS coding increased the potential for missed opportunities for care or services for the affected residents.
Failure to Provide Required Mental Health Services and Support Plan
Penalty
Summary
The facility failed to provide medically-related social services to a resident with a serious mental health illness, as required by both facility policy and the resident's PASRR Level II evaluation. The Social Services Director (SSD) did not review the PASRR Level II screening, which specified the need for a behavioral support plan and a personal support network for the resident. As a result, the resident was not offered any mental health services upon admission, nor was a psychiatric consultation arranged, despite documented diagnoses of major depressive disorder, PTSD, and a history of trauma and abuse. The resident's care plan addressed depression and anxiety but did not include interventions for PTSD or a behavioral support plan as recommended by the PASRR. The care plan interventions were limited to arranging psychiatric consultation and follow-up, which was never documented as completed. Additionally, the resident exhibited behavioral issues, including aggression towards other residents, but interventions focused only on immediate behavioral management rather than addressing underlying mental health needs. Trauma Abuse Screenings completed by the SSD were inaccurately scored, failing to acknowledge the resident's history of abuse, psychiatric diagnoses, and behavioral issues, despite clear documentation in the medical record and PASRR evaluation. The SSD confirmed during interview that she was unaware of the appropriate steps to take when a resident scored points on the trauma screening and did not provide the required mental health services or develop a support plan based on the PASRR recommendations.
Failure to Complete Timely Infection Screening for Antibiotic Stewardship
Penalty
Summary
The facility failed to ensure an effective antibiotic stewardship program when the Infection Preventionist (IP) did not complete an infection screening evaluation to determine if the correct antibiotic was ordered for a urinary tract infection (UTI) for one resident. The IP was responsible for collecting and analyzing infection and antibiotic usage data, as well as implementing evidence-based infection prevention and control practices. However, the IP was not informed by the charge nurse that the resident had a UTI upon return from the emergency room and did not review the resident's orders to check for antibiotics. As a result, the UTI infection worksheet was not completed until several days after the antibiotic was prescribed and administered. The resident involved had been admitted and readmitted with a diagnosis that included UTI and was prescribed Cephalexin for seven days following a positive urine culture for Escherichia coli. The facility's policy required antibiotics to be prescribed and administered under the guidance of the Antibiotic Stewardship Program, with the admitting nurse responsible for reviewing discharge and transfer paperwork for current antibiotic orders. Despite these requirements, the infection screening process was not followed in a timely manner for this resident.
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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 mi | ★★★★★ | 5 | 0 |
| Living Community Of St Joseph | 1.8 mi | ★★★★★ | 0 | 0 |
| Advanced Care Of St Joseph | 2 mi | ★★★★★ | 2 | 0 |
| St Joseph Chateau | 2.3 mi | ★★★★★ | 2 | 0 |
| Belleview Care Center | 2.6 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.