Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Saint Joseph Care Center during CMS and state inspections, most recent first.
Pressure ulcer assessment and wound care failures: The facility failed to complete timely, individualized wound monitoring and to follow ordered wound care for two residents. One resident with severe cognitive impairment, total ADL dependence, and incontinence had a coccyx area first noted as MASD/open skin that was not properly assessed or tracked, and it later was identified by the wound NP as an in-house acquired Stage III PU. Another resident had an unstageable heel PU related to a cast/brace, and during observed care the RN applied skin prep without cleansing the wound first and without required barrier precautions.
RN coverage was not maintained for eight consecutive hours per day. Review of staffing reports, nursing schedules, and daily staffing postings showed no RN coverage on multiple days, and the Facility Scheduler confirmed no RN was scheduled or working for the required hours. The HR Manager stated an RN was on leave and she was unaware of the daily RN coverage requirement until later, while the Administrator acknowledged the requirement had not been followed.
Unclean and Debris-Loaded Dumpster Area: The facility failed to keep the dumpster area clean and sanitary. An observation with the DM found unbagged debris, mostly used gloves, around the dumpster, along with furniture items and housewares piled by the fence. The DM confirmed the area was not kept clean and free of debris, and the facility policy stated trash bags should be sealed before removal and placed in a sealed outdoor container.
Inadequate puree diet portions and missing puree bread. A dietary staff member served puree entrees using smaller-than-listed scoops and did not provide puree bread to five residents on puree diets. The Dietary Manager confirmed the lunch portions were inadequate and that puree bread was not available on the steamtable.
Failure to investigate and self-report alleged verbal abuse: A resident with Parkinson's disease, depression, anxiety, PTSD, and moderate cognitive impairment reported that a male CNA verbally insulted her and called her a liar. She said she did not feel safe around him and worried he might take her belongings or harm her. The CNA said he had heard about the allegations from other staff, and the Administrator stated no SRI had been completed for the allegation despite facility policy requiring prompt reporting and investigation.
Failure to investigate alleged verbal abuse involving a resident who had Parkinson's disease, depression, PTSD, moderate cognitive impairment, and required extensive assistance with ADLs. The resident reported that a male CNA insulted her and called her a liar, and the Administrator acknowledged no SRI or investigation was completed even though the facility knew the resident did not want male caregivers and policy required prompt reporting and a full investigation.
Inaccurate MDS Assessments: The facility failed to ensure MDS assessments were complete and accurate for multiple residents. One resident’s MDS listed a hypnotic and no antibiotic despite MAR/TAR evidence of cefdinir for a UTI and no hypnotic use in the look-back period; another resident’s quarterly MDS listed a hypnotic and antianxiety med that were not supported by orders or MARs. Two other residents’ MDSs omitted hearing aide use and incorrectly indicated unhealed pressure ulcers/injuries when the record showed no wounds during the look-back period.
Inaccurate care plans were identified for two residents. One resident had fall interventions involving dycem, but the care plan did not match the physician orders and the resident had removed the dycem from the wheelchair and recliner. Another resident developed Stage 2 buttock pressure areas and had wound treatment orders, but the care plan only addressed skin risk and did not include an actual skin impairment plan.
A resident with chronic CHF and chronic pulmonary edema did not have ordered daily weights completed on several days despite a care plan intervention and MD order for CHF monitoring. The resident later complained of SOB and was found with low O2 saturation, crackles, and wheezing, and was placed on 2 L O2 with a breathing treatment; later orders included Lasix, potassium, labs, and a chest x-ray. The DON confirmed the missing weights.
A facility failed to honor food and supplement preferences for two residents. One resident with intact cognition reported she did not like cheese on her eggs and preferred cold cereal, yet breakfast was served without the requested cereal and staff said everyone gets the same breakfast daily. Another resident with dementia and a documented preference for chocolate supplement and chocolate pudding received trays with missing items and the wrong supplement flavors, and an RD, ST, and DM confirmed the trays did not match the resident’s preferences.
Failure to use EBP signage and isolation gowns during wound care for two residents with pressure ulcers. An RN Wound Nurse provided wound care to one resident with a coccyx stage 3 PU and another resident with an unstageable heel PU without wearing a protective isolation gown, and the residents were not placed on EBP with signage posted. The nurse also did not cleanse the heel wound with NS before applying skin prep.
A resident with multiple comorbidities and on hospice care, identified as high risk for falls, experienced an unwitnessed fall resulting in a fractured arm and head injury. Despite ongoing behaviors indicating increased fall risk, staff did not update fall risk assessments or care plan interventions after admission, and the bed was found in a high position contrary to recommendations. The facility's failure to provide individualized and effective fall prevention measures led to actual harm.
The facility failed to respond promptly to call lights for two residents, resulting in significant delays in care. One resident with impaired cognition experienced call light wait times of 48 and 42 minutes, while another resident with multiple medical conditions reported waiting 45 minutes to an hour for assistance, leading to cold and inaccessible meals. The DON confirmed these delays.
Pressure ulcer assessment and wound care failures
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized pressure ulcer prevention and wound care program for two residents. For one resident with Alzheimer’s disease, diabetes, neuropathy, venous insufficiency, obesity, generalized weakness, dysphagia, anxiety, severe cognitive impairment, total dependence for ADLs, and bowel and bladder incontinence, the record showed a history of skin risk interventions and an order for barrier ointment to the sacrum for MASD. On 11/04/25, staff identified an area on the coccyx and entered an order to cleanse the area, apply triad paste, and cover with a foam dressing, but there was no initial assessment documenting whether the area was open or MASD and no wound measurements were recorded. The resident’s record then showed repeated treatment orders and skin checks, but no evidence of a wound assessment documenting size, stage, location, or progress from the time the area was first identified until the wound NP evaluated it on 12/29/25. Progress notes referenced an ongoing treatment to an open area on the coccyx, yet there was no documented evaluation of the wound by the physician. The wound NP found the coccyx wound to be an in-house acquired Stage III pressure ulcer measuring 1.5 cm by 0.6 cm by 0.3 cm with moderate exudate and pink granulating tissue. Staff interviews confirmed the wound had first been noted as MASD, that no additional assessments were completed between the initial finding and the NP evaluation, and that the resident was dependent on staff for incontinence care and all ADLs. For the second resident, the wound care note documented an unstageable pressure ulcer to the left heel related to a cast/orthopedic brace, measuring 1.8 cm by 1.5 cm with 100% eschar. During observation of wound care, the RN applied skin prep to the heel without first cleansing it with normal saline and without wearing a protective isolation gown. The RN confirmed the heel was not cleansed before skin prep was applied and confirmed the resident was not placed in enhanced barrier precautions as required. The facility policy required wound assessments to include location, stage, size, drainage, and other wound characteristics, and required physician-authorized wound treatment orders to be followed.
RN Coverage Not Maintained for Required Daily Hours
Penalty
Summary
The facility failed to ensure eight consecutive hours of RN coverage per day. Review of the CMS CASPER Report 1705D for quarter three of fiscal year 2025 showed no RN coverage for more than eight consecutive hours on six identified days. Review of the facility daily nursing schedules also showed no RN assigned, scheduled, or present working on those same days, and the facility’s required daily staffing report postings likewise showed no RN coverage on those dates. Interviews confirmed the staffing deficiency. The Facility Scheduler verified that no RNs were scheduled or could show evidence of RNs working in the facility for eight or more consecutive hours on the identified days. The Human Resource Manager, who oversees scheduling, stated the facility had an RN on leave in May and June of 2025 and reported she was unaware of the requirement for eight consecutive hours of RN coverage per day until July 2025. The Administrator stated she was aware the RN requirement had not been followed in May and June of 2025.
Unclean and Debris-Loaded Dumpster Area
Penalty
Summary
The facility failed to maintain a clean and sanitary dumpster area. During observation on 12/29/25 at 8:26 A.M. with the Dietary Manager, significant unbagged debris, mostly consisting of used gloves, was seen surrounding the dumpster. Various furniture items and housewares were also piled up along the fence surrounding the dumpster. During interview on 12/29/25 at 8:28 A.M., the Dietary Manager confirmed the area was not kept clean and free of debris. Review of the facility policy Waste Disposal, undated, stated that trash bags would be sealed prior to being removed from the facility and that trash would be deposited into a sealed container outside the premises.
Inadequate puree diet portions and missing puree bread
Penalty
Summary
The facility failed to ensure residents receiving a puree diet were served the appropriate portion sizes and complete menu items. During observation of the lunch meal, the puree ham, green beans, and potato casserole and the puree Shepherd's pie were served using a number 10 scoop with an ivory handle, which was confirmed by dietary staff as the scoop sizes used for lunch service. The observation also showed that puree bread was not served to Residents #5, #6, #8, #9, and #11, and the dietary staff member confirmed that puree bread had not been served and was not available on the steamtable. Review of the facility menu showed that lunch included ham, green beans, and potato casserole with a roll and frosted chocolate cake, and that a puree diet should have included pureed casserole, pureed bread, and pureed cake. The diet spreadsheet listed the puree ham, green beans, and potato casserole serving size as an eight-ounce ladle and the puree beef Shepherd's pie serving size as a number six scoop, but the meal was served with smaller portions than listed. The Dietary Manager confirmed that the portion sizes for the puree main menu and alternate menu were inadequate and that puree bread was not served.
Failure to Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to investigate and self-report an alleged incident of verbal abuse involving a resident with Parkinson's disease, depression, atrial fibrillation, anxiety, PTSD, high blood pressure, and chronic constipation. The resident's most recent quarterly MDS showed moderate cognitive impairment and moderate depression, and she required substantial assistance with bathing, transferring, and mobility, including a maximum of two persons for toileting and bed-to-wheelchair transfers. A treatment record later added a restriction that male staff were not to provide personal care assistance on the overnight shift. The resident stated she did not feel safe around a male CNA who had verbally insulted her and called her a liar, and she reported concern that he might take her belongings or harm her. She said the facility was aware of the incident but did not fire him, and she confirmed he had not been providing her care recently but still worked at the facility. The CNA stated he had heard from other staff that the resident was accusing him of calling her a liar and taking belongings, and he said he was told he no longer provided care to her. The Administrator stated she had never completed a self-reported incident related to verbal abuse for the resident, and she was aware the resident did not like male caregivers and did not like this CNA. Facility policy required reporting alleged abuse to the state within 24 hours and completing a full investigation within five days.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to investigate an alleged incident of staff-to-resident verbal abuse involving Resident #3. Resident #3 was admitted with Parkinson's disease, depression, atrial fibrillation, anxiety, PTSD, hypertension, and chronic constipation, and her most recent MDS showed moderate cognitive impairment and moderate depression. She required substantial assistance with bathing, transferring, and mobility, and needed a maximum of two persons for toileting and bed-to-wheelchair transfers. Her TAR later included a treatment note that she was not to have male staff provide personal care assistance, but her care plan and Kardex did not reflect that preference. Resident #3 reported that a male CNA had verbally insulted her, called her a liar, and made her feel unsafe, stating she did not trust him and feared he might take her belongings or harm her. She said the facility was aware of the issue and that the CNA continued to work there, although he had not been providing her care recently. The CNA stated he had stopped caring for her after hearing of the allegations and that he would switch assignments if needed. The Administrator stated she had not completed a self-reported incident or investigation related to the allegation of verbal abuse, despite being aware that Resident #3 did not want male caregivers. Facility policy required reporting alleged abuse to the Ohio Department of Health within 24 hours and completing a full investigation within five days, but no such report or investigation was found.
Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure comprehensive assessments were complete and accurate for four residents reviewed for accurate comprehensive assessments. For Resident #43, the record showed admission and readmission with diagnoses including depression, Alzheimer's disease, and repeated falls. A physician order dated 11/26/25 directed cefdinir 300 mg by mouth twice daily for a UTI, but the admission MDS dated [DATE] indicated the resident was on a hypnotic and not on an antibiotic during the seven-day look-back period from 11/27/25 to 12/03/25. The MARs and TARs showed the last dose of cefdinir was given on 11/27/25 upon rising, and the MARs did not reflect that the resident received a hypnotic during the look-back period. The DON confirmed these findings on 12/20/25. For Resident #4, the quarterly MDS dated [DATE] indicated severe cognitive impairment and that the resident received a hypnotic and an antianxiety medication, but the physician orders and MARs did not show evidence that either medication was ordered or administered. For Resident #22, the record showed diagnoses including dementia, dysphagia, gait/mobility abnormalities, acute kidney failure, hypertension, diabetes, major depressive disorder, spinal stenosis, CKD stage 2, anemia, and anxiety disorder, and that the resident was alert and oriented to person, place, and time and had hearing aides given on 04/04/25; however, the MDS assessments from 06/04/25, 09/04/25, and 12/05/25 did not note hearing aide use. For Resident #5, the quarterly MDS dated [DATE] indicated the resident was at risk for pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries with no stage selected, but the medical record showed no evidence of pressure wounds at the time of the assessment or during the seven-day look-back period. The DON confirmed the MDS section was marked in error.
Inaccurate care plans for fall interventions and skin impairment
Penalty
Summary
The facility failed to ensure residents had accurate care plans for two residents reviewed for care planning. Resident #45 was admitted and readmitted with diagnoses including muscle weakness, history of falling, and acquired absence of the right leg below the knee. His admission MDS showed intact cognition. The fall care plan included an intervention for dycem to the recliner for safety, but the care plan did not reflect the dycem to the wheelchair even though a physician order dated 11/10/25 specified dycem to the wheelchair and another order dated 12/24/25 specified dycem to the recliner. The resident stated he did not like the dycem mat on the wheelchair or recliner and had staff remove it. The DON stated she was unaware it had been removed and later stated the resident did not want the dycem in place and it should have been removed from the physician orders and care plan. Resident #10 was admitted with diagnoses including unspecified displaced fracture of the left humerus, need for assistance with personal care, muscle weakness, and polyarthritis. Her admission MDS showed she had no pressure areas but was at risk for skin impairments and needed partial/moderate assistance with bed mobility. A wound note dated 12/08/25 documented Stage 2 pressure areas to the left and right buttock, and a physician order dated 12/22/25 directed wound cleansing with normal saline, collagen to open areas, and a foam dressing daily and as needed. Her skin care plan addressed risk for skin impairment, but no actual skin impairment care plan was in place. The resident reported she had buttock wounds for a long time and that staff changed the dressings daily and assisted her as needed due to her left shoulder fracture. RN #193 confirmed the resident still had a wound to the left buttock, the right buttock was healed, and that the resident did not have an actual skin impairment care plan.
Missing Daily Weights for CHF Monitoring
Penalty
Summary
The facility failed to ensure a resident with chronic CHF and chronic pulmonary edema had interventions in place for monitoring of CHF. Resident #17 was admitted with diagnoses including chronic pulmonary edema and chronic CHF, and the admission MDS identified debility and cardiorespiratory conditions that included chronic pulmonary edema and heart failure. The resident’s care plan included daily weights as ordered for CHF monitoring, and the physician had ordered daily weights due to CHF. Review of the resident’s weights from 12/13/25 to 12/30/25 showed missing daily weights on 12/16/25, 12/22/25, and 12/26/25. On 12/28/25, the resident complained of shortness of breath, had an oxygen saturation of 87% on room air, and was noted to have audible crackles in the left upper lung and wheezing in the right upper lung. The resident was placed on 2 liters of oxygen and given a breathing treatment, and later that day was ordered a one-time dose of potassium, a one-time dose of Lasix, labs, and a chest x-ray. The DON confirmed the missing daily weights during interview.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor resident food preferences for two residents reviewed for nutrition. Resident #17, who was admitted with chronic pulmonary edema, CHF, and muscle weakness and had intact cognition on admission MDS, had a care plan intervention to provide substitutions for food and fluid dislikes. On observation, she received breakfast with eggs and toast, along with milk, juice, orange juice, and water, while a CNA brought her ginger ale. The menu for that meal offered cereal, cheese scrambled eggs, and toast. During interview, Resident #17 stated she would eat cold cereal but not hot cereal, said she was sometimes tired of eggs, and reported she did not like cheese on her eggs. An LPN stated everyone gets the same breakfast daily and confirmed she was going to get the resident cold cereal because none was on the tray. Resident #43, who had depression, Alzheimer’s disease, weakness, and moderate cognitive impairment, had orders for a regular diet with mechanical soft texture, thin liquids, and a four-ounce high-calorie supplement. Her nutrition care plan and meal tickets reflected a preference for chocolate supplement with meals, and the RD confirmed she liked chocolate flavored supplement and accepted it at 100%. However, observations showed meal trays that did not match those preferences: one dinner tray lacked the chocolate pudding and nutritional shake listed on the ticket, and a breakfast tray contained a vanilla mighty shake instead of chocolate. The ST confirmed the resident was supposed to have a chocolate mighty shake, and the DM stated the facility was out of chocolate shakes, though they had been delivered that day and were still frozen; she also stated staff should have added chocolate syrup to honor the preference. Later, a lunch tray was observed with a strawberry supplement, and the DM again replaced it with vanilla and added chocolate syrup.
Failure to Use EBP Signage and Isolation Gowns During Wound Care
Penalty
Summary
The facility failed to ensure appropriate enhanced barrier precaution signage was in place and that appropriate isolation gowns were used during wound care for two residents with pressure ulcers. Resident #5 had diagnoses including Alzheimer's disease, diabetes mellitus, idiopathic progressive neuropathy, venous insufficiency, obesity, generalized muscle weakness, oropharyngeal dysphagia, and anxiety disorder, and had a BIMS score of 01 indicating severe cognitive impairment. The resident had an in-house acquired stage 3 pressure ulcer to the coccyx measuring 1.5 cm by 0.6 cm by 0.3 cm with moderate exudate and pink granulating tissue. During observation, the RN Wound Nurse completed wound care to the coccyx without wearing a protective isolation gown, and later confirmed the gown was not worn and that the resident was not placed in enhanced barrier precautions with signage indicating precautions were needed. Resident #61 was admitted with diagnoses including nondisplaced bimalleolar fracture of the left lower leg, fibromyalgia, and depression, and had intact cognition on the admission MDS. The resident had an unstageable pressure ulcer related to the cast/orthopedic brace on the left heel, measuring 1.8 cm by 1.5 cm with 100% eschar. During observation, the RN Wound Nurse washed her hands, applied gloves, and applied skin prep to the left heel without cleansing the wound first with normal saline and without wearing a protective isolation gown. She confirmed she did not wear a protective isolation gown and that the resident was not placed in enhanced barrier precautions with signage on the door. The facility policy stated enhanced barrier precautions were indicated for residents with wounds, including chronic wounds such as pressure ulcers.
Failure to Update Fall Risk Interventions Leads to Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate, individualized, and effective fall risk interventions for a resident identified as high risk for falls. The resident, who had multiple diagnoses including atrial fibrillation, anxiety disorder, morbid obesity, and acute kidney failure, was admitted to hospice care and was receiving medications such as morphine and Ativan. Despite being assessed as high risk for falls on admission, no further fall risk assessments were completed until after the resident experienced a fall with injury. The resident's care plan, which initially included fall risk interventions, was not updated to reflect changes in her condition or behaviors that increased her fall risk. Prior to the incident, the resident exhibited terminal agitation, including attempts to get out of bed and remove her clothing. Staff and family members observed these behaviors, and hospice staff recommended keeping the bed in the lowest position. However, on the night of the incident, the resident was found on the floor with her bed in a high position, having sustained a fractured left arm, a laceration to her forehead, and a bruise to her cheek. The bed remote, which controlled the bed's height, was found on the floor next to the resident. There was conflicting information regarding whether staff had entered the room to adjust the bed or provide care prior to the fall. Interviews with facility staff, the administrator, and the DON confirmed that the resident's fall prevention interventions and risk assessments had not been updated since admission, despite her ongoing risk factors and recent behavioral changes. The facility's policy required staff to implement resident-centered fall prevention plans based on current evaluations and data, but this was not done for the resident prior to her fall and injury. The lack of updated assessments and interventions directly contributed to the resident's unwitnessed fall and subsequent harm.
Delayed Call Light Response for Two Residents
Penalty
Summary
The facility failed to respond to call lights in a timely manner for two residents, leading to significant delays in care. Resident #58, who had moderately impaired cognition and required substantial assistance with toilet transfers, experienced call light response times of 48 minutes and 42 minutes on separate occasions. Her family member expressed dissatisfaction with the prolonged wait times, which were reported to the facility's Administrator. Resident #10, who had intact cognition and multiple medical conditions including multiple sclerosis and diabetes, also experienced delays. On one occasion, her call light was activated for 56 minutes, resulting in her breakfast being served cold and inaccessible. She reported multiple instances of waiting 45 minutes to an hour for assistance, which she found unacceptable. The Director of Nursing confirmed the long wait times for both residents during an interview.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Altercare Of Louisville Ctr For Rehab & Nsg Care | 2.1 mi | ★★★★★ | 17 | 0 |
| Green Meadows Skilled Nursing And Rehab | 4.6 mi | ★★★★★ | 0 | 0 |
| Windsor Medical Center Inc | 4.9 mi | ★★★★★ | 1 | 0 |
| Bethany Nursing Home, Inc | 4.9 mi | ★★★★★ | 11 | 0 |
| The Pavilion At Edgefield For Nursing And Rehabili | 5.1 mi | ★★★★★ | 36 | 0 |
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