Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Joseph Residence during CMS and state inspections, most recent first.
Licensed Nurse Coverage Not Maintained 24 Hours a Day: The facility failed to ensure a licensed nurse was on duty 24/7. Review of PBJ staffing data, schedules, and time punches showed multiple days without continuous licensed nursing coverage, and the HR Manager confirmed the findings.
Water Management Plan Not Reviewed or Fully Implemented: The facility failed to implement and annually review its water management plan. The plan identified higher-risk areas such as resident showers, whirlpool tubs, and dead-leg plumbing, but the legionella checklist showed flushing was documented only twice and there was no documentation that shower heads were removed and cleaned. The IP and Maintenance Assistant confirmed the 2017 plan was still being used and had not been reviewed since then.
Inaccurate PBJ Staffing Submission: The facility failed to submit accurate PBJ direct care staffing data to CMS for several days in the quarter. The PBJ report showed no 24-hour LPN/LVN coverage on multiple days and no RN coverage for 8 consecutive hours on several days, but schedules and time punches showed that licensed nursing staff and an RN did work those hours. The HR Manager confirmed that worked hours were not reported in PBJ.
A medication administration error occurred when a Medication Nursing Assistant gave a resident the wrong medication, Docusate Sodium 50 mg/Sennosides 8.6 mg, instead of the prescribed Sennosides 8.6 mg. This mistake was confirmed by the staff member involved, highlighting a failure to follow the facility's policy on adhering to physician's orders.
A resident experienced significant weight loss due to the facility's failure to follow a physician's order for Ensure three times a day with meals. Staff interviews and observations confirmed that the resident did not receive the nutritional supplement, and the order was not documented in the Medication Administration Record or on the meal ticket, contrary to the facility's Supplemental Nourishment Program policy.
A resident consented to receive the PPSV23 vaccine, but the facility failed to administer it. The Infection Preventionist confirmed the oversight, and the facility's policy requires offering appropriate vaccinations to residents aged 65 or older based on CDC recommendations.
The facility failed to submit accurate staffing data to CMS for five days in a fiscal quarter, despite having licensed nurse coverage. The discrepancy was confirmed by HR, highlighting a failure in adhering to the facility's PBJ compliance policy.
Licensed Nurse Coverage Not Maintained 24 Hours a Day
Penalty
Summary
The facility failed to ensure that a licensed nurse was on duty 24 hours a day, 7 days a week, for 8 of 12 days reviewed for Fiscal Year Quarter 4 (July 1, 2025 - September 30, 2025). Review of the Payroll Based Journal staffing data on 12/22/25 showed that licensed nursing coverage was not provided 24 hours a day on multiple dates, including 7/5/2025, 7/12/2025, 7/19/2025, 7/26/2025, 8/2/2025, 8/9/2025, 8/16/2025, 8/23/2025, 8/30/2025, 9/6/2025, 9/7/2025, and 9/21/2025. Review of the facility's schedules and corresponding nursing time punches on 12/23/25 confirmed that there was not licensed nurse coverage on duty 24 hours a day on 7/5/2025, 7/12/2025, 7/26/2025, 8/2/2025, 8/9/2025, 8/16/2025, 9/6/2025, and 9/21/2025. During interview on 12/23/25 at approximately 8:30 a.m., the Human Resource Manager confirmed these findings.
Water Management Plan Not Reviewed or Fully Implemented
Penalty
Summary
The facility failed to implement and review, at least annually, its infection prevention and control water management plan. Review of the water management plan dated 11/13/2017 showed identified areas of greater risk in the nursing home, including resident showers and whirlpool tubs where droplets and moisture are in the air that residents are breathing while bathing, and plumbing fixtures such as sinks and showers at the end of dead-leg piping or in rarely used areas where hot water can stagnate. Review of the facility's legionella checklist showed flushing of hot and cold water in resident rooms, bathrooms, and other areas was documented only on 10/29/25 and 11/28/25, and there was no documentation that shower heads were removed and cleaned. During interview, the Infection Preventionist and Maintenance Assistant stated the 2017 water management plan was still the current plan and that they had no documentation showing it had been reviewed since 2017. They also confirmed the shower heads had not been removed and cleaned and that there was no other documentation for flushing in 2025 except for once in October and once in November.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to submit accurate Payroll Based Journal (PBJ) direct care staffing information to CMS for 7 of 92 days reviewed for Fiscal Quarter 4, July 1, 2025 through September 30, 2025. Review of the PBJ Staffing Data report on 12/22/25 showed that the facility reported no Licensed Nursing coverage for 24 hours on 7/19/25, 8/23/25, 8/30/25, and 9/7/25, and reported no Registered Nurse coverage for 8 consecutive hours on 9/6/25, 9/7/25, and 9/21/25. Review of the facility schedules and time punches on 12/23/25 showed that a licensed nurse was present for each 24-hour period on the listed dates and that a Registered Nurse worked at least 8 consecutive hours on the listed dates. During interview on 12/23/25 at approximately 8:30 a.m., the Human Resources Manager confirmed that hours were worked but not reported in PBJ for the Licensed Nursing staff on the four dates and for the Registered Nurse staff on the three dates. The facility policy stated that the Administrator was responsible for validating all information submitted and that error reports noted by CMS would be investigated and verified.
Medication Administration Error
Penalty
Summary
The facility failed to adhere to professional standards of quality by not following a physician's order during medication administration for one resident. During an observation, a Medication Nursing Assistant, identified as Staff B, was seen preparing medication for a resident. Staff B incorrectly poured a tablet of Docusate Sodium 50 mg/Sennosides 8.6 mg into a medication cup, despite the physician's order specifying only Sennosides 8.6 mg to be administered once daily. This error was confirmed by Staff B during an interview. The facility's policy on medication administration, which mandates adherence to prescriber's written orders, was not followed in this instance.
Failure to Provide Nutritional Supplement as Ordered
Penalty
Summary
The facility failed to follow a physician's order for a nutritional intervention for a resident identified as being at nutritional risk. The resident, who was admitted with a weight of 109 pounds, experienced a weight loss to 101 pounds over a period of approximately two months. A physician's order dated prior to the resident's admission required the resident to receive Ensure three times a day with meals. However, the resident did not receive Ensure as ordered, which was confirmed through observations and staff interviews. During an observation, it was noted that the resident did not have Ensure with their lunch meal. Interviews with various staff members, including a Licensed Nursing Assistant, a Licensed Practical Nurse, and a Cook, confirmed that the resident was not receiving Ensure with meals. The order for Ensure was not included in the Medication Administration Record or on the resident's meal ticket. The facility's policy for the Supplemental Nourishment Program, which aims to provide personalized medical nutrition therapy for residents at nutritional risk, was not followed in this case.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident was offered and/or provided the Pneumococcal vaccine as required. A review of the medical record for a resident revealed that the resident was admitted to the facility and had consented to receive the PPSV23 (pneumococcal polysaccharide vaccine) on a specified date. However, there was no documentation available to show that the resident received the vaccine. An interview with the Infection Preventionist confirmed that the resident had not been given the PPSV23 vaccine despite consenting to it. The facility's policy on immunizations, dated June 9, 2022, states that all residents aged 65 years or older should be offered appropriate vaccination based on their prior pneumococcal vaccine status and new CDC recommendations.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for five days during Fiscal Quarter 3 of 2024. Specifically, the Payroll Based Journal (PBJ) Staffing Data Report indicated that there was no licensed nursing coverage for 24 hours on the dates of April 23, May 26, June 9, June 21, and June 23, 2024. However, a review of the facility's schedules for these dates showed that there was indeed licensed nurse coverage for each 24-hour period. This discrepancy was confirmed during an interview with the Human Resources staff member, who acknowledged that there were missing hours reported for the licensed nursing staff on these days. The facility's policy on PBJ compliance, effective since October 2016, mandates that the Administrator is responsible for validating all information submitted, including employee and contracted/vendor service hours. The policy also requires the Administrator to review all data submitted during the quarter with the HR manager at least four days before the quarterly deadline. Despite these procedures, the facility failed to ensure the accuracy and completeness of the staffing data submitted to CMS, as required by the CMS Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual.
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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 Manchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hanover Hill Health Care Center | 0.1 mi | ★★★★★ | 2 | 0 |
| Saint Teresa Rehabilitation & Nursing Center | 0.4 mi | ★★★★★ | 7 | 0 |
| Mount Carmel Rehabilitation And Nursing Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Maple Leaf Health Care Center | 1.2 mi | ★★★★★ | 2 | 0 |
| Villa Crest Nursing And Retirement Center | 1.3 mi | ★★★★★ | 0 | 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.