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 during CMS and state inspections, most recent first.
Kitchen Food Storage and Sanitation Deficiencies: Surveyors observed lettuce in a steam table pan loosely covered and exposed, another bag of lettuce without a pull or use-by date, a frozen ham thawing on a wire shelf without a drip-proof container or pull date, and a refrigerator tray with spilled residue. In dry storage, hamburger buns were in a bag with a large hole, a sugar bin had a scoop left inside, and storage bins and the refrigerator were soiled. CK A, the DM, and the ADM stated food was expected to be labeled, dated, sealed, and stored in clean areas to prevent contamination.
The facility did not follow its grievance policy by failing to complete investigations and provide written decisions to residents who filed grievances. Review of the grievance log for one month showed 17 grievances with no documented dates of written decisions and incomplete "Findings of Investigation" on most forms. An ADON reported she had not been trained on the grievance process, was unsure if residents received written decisions, and that in-services related to grievances were not documented. The SSD stated she routed grievances to department heads but did not verify completion of investigations or notification to the complainant and was unsure if written communication was provided. The DON acknowledged that department heads typically notified residents verbally and that written responses were not being sent, and the ADM confirmed, after reviewing the policy and grievance forms, that required written follow-up and complete documentation were not being carried out.
A resident with HTN, CKD, and AF had a standing order for a weekly clonidine 0.3 mg/24 hr transdermal patch, but during one month the MAR showed multiple scheduled doses marked as "medication not available" instead of administered. The resident reported not receiving his blood pressure patch and was observed without a patch, while a box of his clonidine patches was later found in a medication cart. Medication aides and LVNs gave differing accounts about when the drug was unavailable, who was notified, and whether the provider or pharmacy were contacted, and leadership (DON and ADM) stated they were not informed of the missing medication despite facility policy requiring timely administration, error reporting, and specific actions when medications are unavailable.
A resident with Ogilvie syndrome and a care plan for altered GI status did not consistently receive ordered bowel medications, including bisacodyl suppositories, lactobacillus, and polyethylene glycol. MARs and nursing notes showed multiple missed doses documented as "on order" or "on reorder," while the resident and the resident’s representative reported ongoing problems with medications running out. A medication aide described a weekly OTC ordering process that could delay obtaining needed OTC drugs, and the DON acknowledged that the resident’s suppositories were not on the current order list despite policies requiring accurate ordering, reordering, and timely administration of medications as prescribed.
A resident with dementia, diabetes, and hypertension, who required significant ADL assistance and had impaired coping, was financially exploited when a CNA took the resident’s debit card and made numerous unauthorized purchases at various stores and gas stations. The resident’s POA discovered the suspicious charges on the card statements, reported them to law enforcement, and did not initially inform facility staff, stating police advised against it and that the facility did not receive the statements. The CNA, whose pre-employment criminal history check showed no disqualifying offenses, was later terminated for no call/no show and subsequently arrested. The facility’s policy stated residents’ rights to be free from abuse, exploitation, and misappropriation and required protocols to prevent and identify theft and to screen employees for abuse- or misappropriation-related findings.
A resident with cognitive intactness and multiple medical conditions, including hemiplegia and a history of cerebral infarction, had a care plan for inadequate nourishment that included therapeutic supplements and a physician order for Ensure Clear with the noon meal. Despite this, the resident reported not receiving the supplement, and surveyor observation of a lunch tray confirmed its absence. The resident’s representative stated she had repeatedly raised the issue at care plan meetings, and the SW recalled being told about the need for Ensure Clear but did not verify follow‑through. The DON was unaware the supplement was not being given, even though facility policy requires medications and ordered items to be administered as prescribed.
A resident with a PICC line did not have her dressing changed according to physician orders and facility policy, despite documentation by an LVN indicating the task was completed. The DON confirmed the dressing was not changed as required, and the discrepancy was identified through observation and record review.
Expired bottles of Melatonin 1mg and Aspirin 325mg were found on a medication cart during a survey. An LVN acknowledged responsibility for removing expired medications in the absence of a medication aide, and the DON confirmed staff are expected to check for expired drugs before administration. The facility's policy requires nursing staff to maintain medication storage and remove outdated medications, but these expired drugs remained on the cart.
A medication cart was found with a bottle of lactulose that was sticky and adhered to the drawer, indicating improper storage and lack of cleanliness. An LVN acknowledged the issue, and the DON stated that staff are responsible for ensuring medications are stored properly, as outlined in facility policy.
A resident with a stasis ulcer did not receive wound care in accordance with infection control protocols when an LVN failed to perform hand hygiene before and between glove changes, used gloves stored in a scrub pocket, and did not clean the overbed table before placing supplies. Both the LVN and DON confirmed these actions did not follow facility policy.
A deficiency was cited when a resident was found to have been prescribed or administered unnecessary drugs, with no adequate clinical justification documented in the medical record.
The facility did not ensure that laboratory services or tests were provided in a timely and quality manner to meet resident needs, as identified by surveyors.
Nurse staffing information, including the number and hours worked by RNs, LPNs, and CNAs, as well as the facility name, date, and resident census, was not posted as required. Staff schedules were available in a lobby binder but did not meet regulatory requirements, and staff interviews revealed confusion about the posting process and responsibilities.
A resident prescribed Modafinil for sleep apnea did not receive the medication after it was delivered and signed for by nursing staff. The medication and its count sheet went missing after two nurses failed to perform the required shift change narcotic count, with both nurses admitting to not following facility policy for controlled substance accountability. The medication was never found, and the required procedures for receiving, recording, and securing controlled substances were not followed.
Several residents with complex medical needs did not have complete or accurate documentation of medication, treatment, and wound care administration. MARs, TARs, WARs, and Controlled Drug Records were missing or inconsistent, and staff interviews revealed confusion and lapses in following documentation procedures. The facility's narcotic record logs were also disorganized, with missing records for discontinued medications and discharged residents.
Three residents did not have comprehensive, individualized care plans addressing their specific needs, including refusal of monthly weights, refusal to sit upright during meals, and use of respiratory equipment. Care plans lacked documentation of refusals, individualized interventions, and necessary physician orders, resulting in unmet care needs.
Three dependent residents did not receive scheduled showers as required by their care plans, with missing or inaccurate documentation in both EHR and paper records. Staff interviews revealed inconsistent documentation practices and short staffing, leading to missed bathing care and resident dissatisfaction.
Multiple nourishment room refrigerators were found without required temperature logs, contained expired food items, and showed evidence of poor sanitation, including stains, a human hair, and pest activity. Staff interviews revealed confusion over responsibilities for cleaning and monitoring, and a review of the facility's contract confirmed divided duties between the facility and the contracted kitchen.
Two residents did not have their comprehensive admission MDS assessments completed within the required 14-day period. Both assessments were overdue, with one resident's assessment 2 days late and the other 9 days late. Staffing challenges and workload issues among MDS coordinators contributed to the delay, and the facility did not provide a policy on timely MDS completion when requested.
A resident with dementia and moderate cognitive impairment was not properly assisted or positioned to eat her meal in bed, leaving her unable to reach or see her food. Staff were unclear about who placed the tray, and the resident's care plan required assistance with eating, which was not provided according to facility policy.
A medication aide failed to confirm that a resident with impaired cognition and swallowing difficulties consumed her nighttime medications, resulting in unconsumed pills being found in the resident's room. The aide was unaware of a physician's order to crush medications, and staff were not informed of the resident's difficulty swallowing, leading to a lapse in medication administration according to professional standards.
A resident with multiple chronic conditions was using a CPAP machine nightly and a nebulizer as needed, but there were no physician's orders or care plan interventions documented for either device. Nursing staff confirmed the use of these devices without proper documentation, and there was no record of equipment maintenance or cleaning schedules.
A resident with multiple medical conditions did not receive prescribed Thiamine and Ergocalciferol because these medications were not available at the time of administration. Staff interviews revealed inconsistent communication and unclear procedures regarding reporting and obtaining unavailable medications, and no policy on medication availability was provided during the survey.
A medication error rate above 5% was identified when a resident with complex medical needs did not receive prescribed Thiamine and Ergocalciferol because the medications were not available. The medication aide reported the issue to a nurse, but the nurse was unaware of the shortage, leading to missed doses and a failure to follow facility policy for medication administration and communication.
A medication aide left a medication cart unlocked and unattended in a hallway, with over-the-counter medications left out on top of the cart while administering medications in a resident's room. The aide acknowledged that the cart should not be left unlocked or with medications exposed, and the DON confirmed that staff are expected to keep carts locked unless in use, as per facility policy.
A medication aide did not perform hand hygiene or wear gloves before and after administering prescribed eye drops to a resident with multiple medical conditions, including sepsis and glaucoma. This lapse was observed by surveyors, and the aide later acknowledged the failure to follow infection control procedures, which are required by facility policy and staff training.
The facility failed to assess and obtain informed consent for bed rail use for three residents, leading to potential risks of entrapment and injury. Observations showed residents with side rails up, but records lacked documentation of care plans, physician orders, and risk assessments. Interviews revealed that bed rails were used as enablers without proper consent or assessment, contrary to facility policy.
The facility failed to notify residents of a change in their attending physician after terminating the Medical Director's agreement. This affected several residents, who were not informed about the change, leading to a lack of choice in their medical care. The administration admitted the oversight, but there was no evidence of proper notification being distributed.
A resident's medications were left unsecured on a medication cart, and a loose pill was improperly disposed of in a trash can. The facility's policies require medications to be locked or attended by staff and disposed of in a sharps container. Staff interviews confirmed these expectations, but additional policies were not provided during the survey.
A resident was found with a bleeding head wound less than 24 hours after admission, but the facility failed to report the incident to the state agency within the required 24-hour timeframe. The delay occurred because the administrator waited for corporate approval before reporting.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During an initial tour of the kitchen, surveyors observed a stainless-steel steam table pan containing lettuce with a sheet of clear plastic wrap loosely covering it and falling into the lettuce, leaving the contents exposed to open air. An additional clear bag of lettuce was observed wrapped in plastic wrap with no pull date or use-by date. A large frozen ham was observed thawing on the bottom wire shelf without being placed in a drip-proof container and without a pull date for defrosting. The bottom of the refrigerator also contained a tray with a white milky spilled substance that covered part of the tray and the bottom of the refrigerator. In the dry storage room, surveyors observed a shelf of bread containing a clear bag of hamburger buns with a baseball-size hole that exposed the bread to open air. Four dry storage bins with blue lids were also observed; one contained sugar with the plastic scoop left buried inside the sugar, and the bins were soiled on top with white powder residue. The report also noted soiled interior surfaces of the reach-in refrigerator. These observations were made during the kitchen sanitation review and were documented as failures to maintain food storage in a manner that prevented contamination and to maintain a sanitary environment. During interviews, the CK A, DM, and ADM each stated that stored foods were expected to be labeled and dated, sealed or covered to prevent contamination, and kept in clean kitchen and storage areas. CK A stated that items without a pulled date or use-by date could be unknown in age and could have gone bad. The DM stated that lettuce should have been completely sealed, bread should have been tied or closed, scoops should not be left in dry storage bins, and kitchen areas including refrigerators and bins should be cleaned after every meal service. The ADM stated that items in the refrigerator should be labeled and dated, salad or lettuce mix should be covered and have a use-by date, dry storage scoops should be stored separately, bread should be sealed, and the kitchen should be cleaned daily and as needed after each meal.
Failure to Provide Written Grievance Decisions and Complete Investigations
Penalty
Summary
The facility failed to honor residents’ grievance rights by not ensuring prompt resolution and written notification of grievance outcomes for all four confidential residents reviewed. Review of the March 2026 grievance log showed 17 grievances, with the “Date of Written Decision” column left blank for every entry. The log also indicated that 10 of the 17 grievances lacked completion of the “Findings of Investigation” section, leaving the nature and results of the investigations undocumented on the forms. Interviews with key staff revealed a lack of training, unclear responsibility, and inconsistent documentation related to the grievance process. The ADON reported signing 12 of the 17 March grievances but stated she had not been trained on how to complete a grievance or conduct an investigation. She described that when a grievance related to nursing was received, the SSD would pass it to her or the DON, and that in-services and re-education were sometimes provided to staff, including 1:1 sessions, but there was no record of these educational efforts. She also stated she was unsure whether residents were receiving written decisions regarding their grievances. The SSD stated she was responsible for receiving, reviewing, and routing grievances to the appropriate department, and that the investigating department head was responsible for completing the grievance form, including investigation, outcome, and notification. She indicated she did not verify that the forms were completed correctly, that investigations were thorough, or that the person filing the grievance was notified, and she was unsure if written communication was provided to residents. The DON acknowledged she had not recently read the grievance policy and stated that department heads were responsible for completing investigations and notifying the complainant verbally, with no written responses being provided. The ADM, after reviewing the grievance policy and the March grievances, stated the policy was not being followed, noted blank sections on the grievance forms, and confirmed that written follow-up was not being provided to persons filing grievances, despite the policy requiring written responses and written summaries of investigations.
Failure to Ensure Availability and Administration of Ordered Clonidine Patch
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident had prescribed clonidine 0.3 mg/24 hr transdermal patches available and administered as ordered for essential hypertension. The resident was an older male with chronic kidney disease, essential hypertension, and atrial fibrillation, with a BIMS score indicating moderate cognitive impairment. His physician’s order, in place since January, directed application of one clonidine patch weekly on Saturdays. Review of the March MAR showed the resident was scheduled to receive the clonidine patch on four specific dates in March, but on each of those dates the MAR was marked with a “9,” which the MAR key defined as “medications not available,” instead of being signed as administered. Blood pressure records for March showed multiple readings throughout the month, including several elevated values. The resident reported to surveyors that the facility had recently changed pharmacies and that he had not received his blood pressure patch in over a week; he believed his blood pressure was elevated due to the missed patch and stated he did not have a patch on at the time of the interview. On observation of the unit 3 medication cart, surveyors found a box of clonidine 0.3 mg/24 hr patches labeled with the resident’s name, dated earlier in March, stored in the cart drawer. The DON later confirmed that the clonidine patches were in the unit 3 medication cart and that a skin assessment revealed no clonidine patch on the resident. Multiple staff interviews showed inconsistent awareness and follow-through regarding the missing medication. Medication aides stated that on several March dates they could not locate the clonidine patches at medication pass, marked the MAR with a “9,” and reported the issue to the charge nurse, but they were unsure whether the provider was notified each time or whether the medication was obtained from the pharmacy or emergency sources. One MA reported that the patches were later found in the nurses’ medication cart by an LVN, but she did not know if a patch was then applied. Several LVNs, including the charge nurse, stated they were not informed that the resident was out of clonidine patches, did not recall seeing the patches on the resident in March, or only became aware when the resident himself mentioned missing doses. The DON and ADM both stated they were not notified in March that the resident was out of clonidine patches, despite facility policy requiring safe, timely administration of medications, documentation and review of medication errors, and specific steps when medications are withheld or unavailable. The attending MD stated that missing clonidine patches for a month could cause the resident’s blood pressure to go up and that he had not been aware the medication had not been administered for March until after reviewing the record. He noted the resident’s blood pressure had been stable with occasional spikes and reported that the NP told him she had been notified by staff via text message about the missing medication. The facility’s written medication administration policy required that medications be administered as prescribed, that medication errors be documented and reviewed by QAPI, and that withheld or refused drugs be properly documented on the MAR. Despite these requirements, the resident’s clonidine patches were repeatedly documented as not available, remained misplaced in medication storage areas, and were not administered as ordered throughout March, leading to the cited deficiency in pharmaceutical services and medication administration.
Failure to Ensure Continuous Availability and Administration of Ordered Medications for Bowel Management
Penalty
Summary
Surveyors identified a failure to provide pharmaceutical services to meet the needs of a resident with Ogilvie syndrome, hemiplegia, and hemiparesis following a cerebral infarction. The resident was cognitively intact per a recent MDS and had a care plan focus on altered gastrointestinal status related to Ogilvie syndrome, with interventions including administering medications as ordered and monitoring side effects and effectiveness. Physician orders included bisacodyl rectal suppository 10 mg daily, lactobacillus two tablets by mouth daily, and polyethylene glycol 17 grams by mouth twice daily. Record review of the MAR showed that the resident did not receive lactobacillus for several consecutive days, did not receive polyethylene glycol on two days, and did not receive the ordered bisacodyl suppository on another day. Nursing progress notes documented that lactobacillus and polyethylene glycol were not administered because they were "on order" and that the bisacodyl suppository was not administered because it was "on reorder." The resident reported he was not getting his constipation medications consistently, stated he had run out of medications, and specifically noted he did not receive his suppository the previous night because staff told him they had run out. The resident’s responsible party reported that running out of the resident’s medications had been an ongoing problem and that he had missed multiple doses of lactobacillus, polyethylene glycol, and bisacodyl suppositories. A medication aide stated that the resident’s polyethylene glycol and probiotic were OTC medications and explained that OTC orders had to be submitted to the DON on a specific day of the week, with delivery occurring later, and that missing the weekly order meant waiting until the next week. The DON stated that OTCs were ordered a week ahead, that the facility had a contract with a local pharmacy that could supply OTCs, and that residents should not run out of medications, while acknowledging that the resident’s suppositories were not on the current week’s delivery list. Facility policies required accurate documentation and management of medication ordering, reordering, dispensing, and receipt through the EHR, and required medications to be administered in a safe and timely manner as prescribed.
Failure to Protect Resident From Financial Exploitation and Misappropriation of Property
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from exploitation and misappropriation of property by a CNA. The resident was an elderly female with dementia, diabetes mellitus, and hypertension, admitted with severe cognitive impairment as evidenced by a BIMS score of six and requiring partial to substantial assistance with all ADLs. Her care plan included interventions for impaired coping, such as encouraging rest and involving the resident or representative in determining next steps in care. Despite these needs and vulnerabilities, a CNA employed at the facility from late October to early December took the resident’s debit card at some point during her employment and used it for personal purchases. Law enforcement records reviewed by surveyors indicated that the CNA allegedly committed financial exploitation of the resident over a period of several months, resulting in at least 36 unauthorized charges on the resident’s debit card at liquor stores, grocery stores, and gas stations in multiple cities. The exact dollar amount was not yet determined because the matter remained under investigation. The CNA’s criminal history check, completed prior to hire, did not reveal any disqualifying offenses, and the facility’s records showed she was terminated for no call/no show, with no documented complaints about her performance while employed. The resident’s responsible party, who held power of attorney and received the debit card statements, discovered numerous charges that the resident could not have made and reported the matter directly to law enforcement without informing the facility, stating that police advised him not to notify the facility until further investigation. He also stated that the facility could not have known about the charges because the statements were sent only to him. The facility became aware of the alleged misappropriation when it received a subpoena from a detective requesting employment and termination records for the CNA. At the time of surveyor observation and interview, the resident did not voice complaints about staff treatment or missing personal items. The facility’s written policy stated that residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that the facility would develop and implement policies and protocols to prevent and identify theft, exploitation, or misappropriation of resident property and conduct background checks to avoid employing individuals with findings related to abuse or misappropriation.
Failure to Provide Physician‑Ordered Nutritional Supplement at Lunch
Penalty
Summary
The deficiency involves the facility’s failure to provide a physician‑ordered nutritional supplement to a resident with identified nutritional concerns. The resident, who had diagnoses including Ogilvie syndrome, hemiplegia and hemiparesis following a cerebral infarction, had a comprehensive care plan focus area for "state of nourishment, less than body requirement" characterized by weight loss, inadequate intake, and decreased appetite, with interventions that included providing therapeutic supplements. The consolidated physician orders included an order for Ensure Clear with the noon/lunch meal once daily. Despite this, observation of the resident’s lunch tray showed no supplement present, and the resident reported that he was supposed to receive a supplement at lunch but that staff never gave it to him. The resident’s responsible party reported that the resident was not receiving his Ensure Clear as ordered and stated she had raised this concern at the last two care plan meetings, including one documented meeting where the care plan noted the need for clear Ensure. The social worker confirmed remembering the family’s report about the Ensure Clear and stated she believed she had passed the information on to nursing but did not follow up to ensure the supplement was provided. The DON stated she was not aware the resident was not receiving the ordered supplement and indicated there was no reason the supplement should not have been provided if ordered. The facility’s provided policy on administering medication stated that medications are to be administered in a safe and timely manner and as prescribed, but the resident’s ordered supplement was not administered with his lunch as required.
Failure to Change PICC Line Dressing per Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure that parenteral fluids were administered in accordance with professional standards of practice and physician orders for one resident. The resident, a cognitively intact female with a history of Staphylococcal arthritis, sepsis, and methicillin-susceptible staphylococcus aureus infection, was admitted with orders for IV medication and a peripherally inserted central catheter (PICC) line. The care plan required weekly monitoring and dressing changes for the PICC line, and physician orders specified that the dressing should be changed every week and as needed. Upon review, it was found that the resident's PICC line dressing was dated eight days prior to the observation, despite documentation indicating that the dressing had been changed as scheduled. The dressing was signed off as changed by an LVN, but direct observation and the date on the dressing indicated that the change had not actually occurred. The DON confirmed that the dressing had not been changed as required and that it was inappropriate for staff to document completion of a task that was not performed. Facility policy also required dressing changes at least every seven days to prevent complications, but this was not followed in this instance.
Expired Medications Found on Medication Cart
Penalty
Summary
Expired medications were found on the station one medication cart during an observation, specifically one bottle of Melatonin 1mg and one bottle of Aspirin 325mg, both expired as of 08/2025. The facility's policy requires nursing staff to maintain medication storage areas and ensure that discontinued, outdated, or deteriorated medications are removed and handled according to pharmacy instructions. However, these expired medications remained on the cart past their expiration date. During interviews, an LVN stated that it was the medication aide's responsibility to ensure expired medications were not present, but since there was no medication aide at the time, the LVN acknowledged it was his responsibility while passing medications. The DON confirmed that both medications were expired and stated that staff are expected to check medications prior to administration to ensure they are not expired. The presence of expired medications on the cart indicated a failure to follow established procedures for medication management.
Failure to Maintain Clean and Orderly Medication Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and cleanliness of drugs and biologicals on one of four medication carts reviewed. Specifically, a bottle of lactulose was found in the medication cart drawer with sticky residue on its sides, and the bottle was stuck to the bottom of the drawer. During interviews, an LVN acknowledged that the bottle was sticky and should have been cleaned, and the DON confirmed that staff are expected to check medications prior to administration to ensure proper storage. Review of the facility's medication labeling and storage policy indicated that medications should be stored in an orderly manner and that nursing staff are responsible for maintaining medication storage areas in a clean, safe, and sanitary condition. The observed failure to maintain cleanliness and orderliness in the medication cart drawer directly contradicted the facility's policy and could affect the integrity of medications stored within.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with a right lower extremity (RLE) stasis ulcer. During wound care, an LVN did not perform hand hygiene prior to the procedure, between glove changes, or after glove removal. The LVN also used gloves that had been stored in the pocket of his scrub pants, which were considered contaminated, and did not clean the overbed table before placing treatment supplies on it. These actions were observed during a wound care procedure, and the LVN acknowledged not following proper hand hygiene protocols and not ensuring a clean field for the supplies. The resident involved was an older female with diagnoses including alcohol dependence, major depression, and muscle wasting, and had a care plan for potential impaired skin integrity. Physician orders required specific wound care procedures, including cleansing and dressing changes. Facility policies on hand hygiene and wound care were reviewed, which outlined the need for handwashing before resident contact, between glove changes, and after glove removal, as well as the use of a clean field for supplies. The LVN and DON both confirmed that the observed practices did not align with facility policy.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Failure to Provide Timely, Quality Laboratory Services
Penalty
Summary
The facility failed to provide timely and quality laboratory services or tests to meet the needs of residents. This deficiency was identified through surveyor observation and review of facility practices, indicating that laboratory services were not delivered in a manner that met the required standards for resident care. No additional details regarding specific residents, their medical history, or the exact nature of the laboratory service delays or deficiencies are provided in the report.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was properly posted as required. On the day reviewed, there was no posted nurse staffing information in the building, including in the lobby, nurse's stations, or hallways. Although a binder containing staff schedules was present in the front lobby, it did not include the required details such as the total number and actual hours worked by registered nurses, licensed practical/vocational nurses, and certified nurse aides for each shift, nor did it include the facility name, current date, or resident census. Multiple locations were checked, and the required posting was not found. Interviews with facility staff revealed a lack of understanding and awareness regarding the nurse staffing posting requirements. The DON believed the schedule binder met the requirement and was unaware of the specific posting obligations or how to generate the necessary report from the electronic system. The RNC was aware of the requirement but did not realize the facility was not in compliance, and confirmed that the schedule binder did not meet the requirement. The facility's policy stated that nurse staffing information should be posted daily in a clear and accessible format, but this was not followed.
Failure to Account for and Secure Controlled Substance Due to Missed Shift Change Narcotic Count
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident. Specifically, a resident with diagnoses including sleep apnea, morbid obesity, and epilepsy was prescribed Modafinil 100 mg tablets for sleepiness related to sleep apnea. The medication, consisting of 30 tablets, was delivered by the pharmacy and signed for by a nurse, but was never administered to the resident and was reported missing the following day. The investigation revealed that the medication was received by one nurse and handed over to another, who reported placing it in the narcotic storage box with the pharmacy's count sheet. However, during the subsequent shift change, the required narcotic count was not performed by the two nurses responsible. Both nurses admitted in interviews that they did not count the narcotics together at shift change, contrary to facility policy. One nurse stated she counted the narcotics alone, while the other left the cart keys in the narcotic book and did not participate in the count. The medication and the count sheet were subsequently discovered missing, and a search of all medication carts and rooms failed to locate the missing Modafinil. Facility records and interviews confirmed that the required procedures for controlled substance accountability were not followed. The facility's policy mandates that controlled substances be signed for by two nurses, immediately recorded, and stored securely, with counts performed at each shift change. The failure of the nurses to conduct the shift change narcotics count and properly secure the medication led to the loss of the resident's Modafinil, with no resolution as to its whereabouts.
Incomplete and Inaccurate Medical Record Documentation for Medications and Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three residents reviewed for medication, treatment, and wound administration. Specifically, there were multiple instances where Medication Administration Records (MAR), Treatment Administration Records (TAR), Wound Administration Records (WAR), and Controlled Drug Records were either incomplete, missing, or inaccurately documented. For example, one resident's records for Norco, Pregabalin, tramadol, and wound cleanse treatments were not properly completed or accurately reflected in the MAR, TAR, WAR, and Controlled Drug Records. Another resident's MAR for Lorazepam was missing for two consecutive months, and the documented dose did not match the Controlled Drug Record. A third resident's MAR and Controlled Drug Record for Hydrocodone showed discrepancies in the number of doses administered. Interviews with nursing staff, the DON, and other facility personnel revealed a lack of consistent procedures and understanding regarding documentation requirements. Staff reported that medication errors were not always documented or reported as required, and there was confusion about the retention and submission of narcotic logs, especially for discontinued medications and discharged residents. The DON and other staff acknowledged that documentation practices were not being followed correctly, and some staff expressed concerns about the accuracy and completeness of the records. Additionally, there were reports of medical record entries being removed or edited, further contributing to the lack of reliable documentation. The affected residents had significant medical needs, including pain management for conditions such as cellulitis, end-stage renal disease, morbid obesity, schizoaffective disorder, and dementia. Despite active orders for medications and treatments, the facility's failure to document administration accurately and completely meant there was no reliable record to confirm that residents received their prescribed care. The absence of proper documentation also extended to the facility's narcotic record logs, which were found to be disorganized and inconsistent, with multiple forms in use and missing records for some residents.
Failure to Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in unmet needs related to their physical, mental, and psychosocial well-being. For one resident with a history of muscle wasting, atrophy, and cognitive communication deficit, the care plan did not address the resident's ongoing refusal to be weighed monthly, despite a physician's order and documentation of refusals in progress notes. The care plan only included general interventions for monitoring signs of malnutrition, without specific strategies for addressing the resident's refusal to be weighed or alternative monitoring methods. Another resident with a history of a left arm fracture, diabetes, malnutrition, and dysphagia had a care plan that failed to address repeated refusals to sit up at a 90-degree angle during meals, as ordered by the physician. Despite documentation of multiple refusals and the resident's report of dizziness when sitting upright, the care plan did not include individualized interventions to address these refusals or alternative approaches to ensure safe feeding and aspiration prevention. Staff interviews and documentation indicated that the resident was not consistently offered the opportunity to sit up for meals, and the care plan was not updated to reflect these ongoing issues. A third resident with dementia, diabetes, sleep apnea, and congestive heart failure used both a CPAP machine and a nebulizer, but the care plan did not address the use, maintenance, or monitoring of these devices. There were no physician orders for the CPAP or nebulizer in the electronic health record, and no documentation of cleaning schedules or replacement parts. Staff and family interviews confirmed the resident's long-term use of these devices and the lack of documentation or care planning related to their use. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables, but these requirements were not met for the residents involved.
Failure to Provide Scheduled Showers and Accurate Documentation for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing, to three residents who were dependent on staff for personal hygiene. Documentation review revealed that scheduled showers for these residents were not consistently provided according to their care plans and facility protocols. Electronic health records (EHR) and paper shower sheets were either missing, incomplete, or contained inaccurate entries, with staff admitting to documenting tasks in the EHR to avoid system alerts, regardless of whether the care was actually provided. One resident, a female with multiple diagnoses including non-traumatic brain dysfunction, stroke, and partial paralysis, was physically dependent on staff for bathing and required a mechanical lift for transfers. Despite being scheduled for showers three times a week, there was no evidence in the shower binder or EHR that these showers were provided. Both the resident and her family member reported that she did not refuse showers and felt unclean due to missed bathing. Staff interviews confirmed that documentation practices were inconsistent and sometimes inaccurate, with reliance on paper records that were not always completed or retained. Two other residents, both male with significant medical conditions such as dementia, diabetes, and acute kidney failure, also did not receive scheduled showers. One had only a single, undated shower sheet in the binder, and the other had only two completed shower sheets for the review period, with no EHR documentation. Family members reported delays in bathing and related health issues, such as a yeast infection. Staff interviews indicated that short staffing on certain shifts contributed to missed showers, and that documentation was often incomplete or not performed in real time, contrary to facility policy.
Deficient Food Storage, Sanitation, and Temperature Monitoring in Nourishment Refrigerators
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and distribution practices in accordance with professional standards for food service safety in several nourishment room refrigerators. Observations revealed that temperature logs were not maintained or visible on multiple refrigerators, including those in dining rooms and nourishment rooms. Inside the refrigerators, there were visible stains, a human hair, and expired food items such as sour cream packets and half & half cups. Additionally, a multi-use tub of homemade ice cream was found in a freezer without a resident's name or date. One nourishment refrigerator was found to have sugar ants crawling along the freezer door seal. Interviews with facility staff, including the ADON, DON, and ADM, revealed confusion and inconsistency regarding responsibility for maintaining temperature logs, cleaning, and disposing of expired foods. The facility's contract with the contracted kitchen indicated that the kitchen was responsible for stock and cleanliness, while the facility was responsible for temperature monitoring. Pest control invoices confirmed that pest control services had been provided in the months prior to the observations.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission assessments (MDS) within the required 14-day timeframe for two residents. One resident, a male with diagnoses including acute kidney failure, altered mental status, osteoarthritis, low potassium, and hyperosmolality, was admitted but did not have a completed admission MDS assessment within 14 days; the assessment was still in progress and noted as overdue. Another male resident with diagnoses of unspecified dementia, diabetes, sleep apnea, hypertension, atrial fibrillation, congestive heart failure, and GERD also did not have a completed admission MDS assessment within the required timeframe, with the assessment similarly overdue. Interviews with MDS staff revealed that one MDS coordinator had been the only person in the role until recently and had become overwhelmed with new admissions, while the newly hired MDS coordinator was still orienting and attempting to catch up on the workload. The facility did not provide a policy on the timing for completion of MDS assessments when requested. The MDS job description and the Resident Assessment Instrument User's Manual both require that admission MDS assessments be completed within 14 days of admission.
Failure to Assist Resident with Eating Due to Improper Positioning
Penalty
Summary
A deficiency occurred when a female resident with dementia, chronic obstructive pulmonary disease, and anorexia was not provided with the necessary assistance to maintain her ability to perform activities of daily living, specifically eating. The resident's assessment indicated moderate cognitive impairment and a need for setup or clean-up assistance with eating, but no swallowing disorder or weight loss. Her care plan specified that staff assistance was required for eating. During observation, the resident was found in bed with her breakfast tray placed at chin level, unable to see or reach her food, and stated she needed to be repositioned to eat. Interviews with the DON and CNAs revealed uncertainty about who placed the tray and confirmed that the resident was not properly positioned to feed herself. The facility's policy requires that residents receive care and services to maintain their abilities in activities of daily living, including eating, based on their comprehensive assessment. The failure to monitor the resident's assistance needs and ensure proper positioning resulted in the resident being unable to access her meal.
Failure to Ensure Resident Consumed Medications as Ordered
Penalty
Summary
A deficiency occurred when a medication aide (MA) failed to ensure that a resident with multiple diagnoses, including non-traumatic brain dysfunction, stroke, seizure disorder, and dysphagia, consumed her nighttime medications as ordered. The resident, who had moderately impaired cognition, was observed to have spit out her medications and stored them in her bedside table after the MA left the room without confirming ingestion. Family members discovered the unconsumed pills and reported that the MA had rushed the resident, not allowing sufficient time for safe medication administration. The MA was also unaware of a standing physician order permitting medications to be crushed and mixed with food or jelly, which could have facilitated safer administration for the resident with swallowing difficulties. Interviews with facility staff revealed that neither the charge nurse nor the DON were aware of the resident's difficulty swallowing medications or the incident of spitting out pills. The MA stated she believed the resident had swallowed the medications and was not aware of the crush order. The facility's medication administration policy requires medications to be administered as ordered, including crushing medications when specified. The failure to ensure the resident consumed her medications as ordered and in accordance with professional standards led to the identified deficiency.
Lack of Physician Orders and Care Plan for Respiratory Devices
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required the use of a CPAP machine and a nebulizer. The resident, an elderly male with multiple diagnoses including dementia, diabetes, sleep apnea, congestive heart failure, and atrial fibrillation, was observed using a nebulizer mask and had both a CPAP machine and a nebulizer present in his room. Despite this, there were no physician's orders or care plan interventions documented for the use of either device in the resident's electronic health record (EHR). The care plan only addressed monitoring for labored breathing and use of accessory muscles, and the physician's orders included only PRN albuterol for shortness of breath or wheezing, but not the use of the CPAP or nebulizer machines themselves. Interviews with nursing staff confirmed that the resident used the CPAP nightly and the nebulizer as needed, but acknowledged that no orders for these devices were present in the EHR. Staff relied on their knowledge of the resident's routine rather than documented orders or care plans. Additionally, there was no documentation regarding the replacement of parts or cleaning schedules for either respiratory device. The resident's family member also confirmed the long-term use of the CPAP and nebulizer and noted that the facility was in the process of obtaining a new CPAP machine for the resident.
Failure to Ensure Timely Availability of Prescribed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the availability of prescribed medications, specifically Thiamine and Ergocalciferol. The resident, who had diagnoses including sepsis, anxiety, myasthenia gravis, and mild protein calorie malnutrition, was admitted with a care plan that included medication supplements to maintain nutritional status. Record review showed that the resident had active orders for Thiamine and Ergocalciferol, but the Medication Administration Record indicated these medications were not administered because they were on order and not available at the facility. During medication pass, the medication aide prepared the resident's medications except for the unavailable Thiamine and Ergocalciferol, documenting their absence. The aide reported the missing medications to the charge nurse but was unsure why they had not arrived. Interviews with staff revealed inconsistent communication regarding the unavailability of medications, with the charge nurse stating she was not informed and the DON outlining procedures that were not followed. The facility did not provide a policy on medication availability during the survey.
Medication Error Rate Exceeds Threshold Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, resulting in a medication error rate of 7.69% based on 2 out of 26 observed opportunities. This deficiency involved a resident with multiple diagnoses, including sepsis, anxiety, myasthenia gravis, and mild protein calorie malnutrition, who did not receive ordered doses of Thiamine and Ergocalciferol because the medications were not available for administration. The resident's care plan included medication supplements to maintain adequate nutritional status, and the medication administration record confirmed the missed doses, noting the medications were on order. During medication pass observation, the medication aide prepared all available medications but omitted the unavailable ones, documenting them as on order. The aide reported the missing medications to the charge nurse, but the nurse later stated she was not informed about the unavailability. The facility's policy required staff to administer medications as ordered and to report unavailable medications to nursing leadership, but this process was not followed, resulting in the resident not receiving prescribed medications as scheduled.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication aide (MA) left a medication cart unlocked and unattended in the hallway outside a resident's room. Over-the-counter medications, including Oscal (a calcium supplement) and a Vitamin D supplement, were left out on top of the cart while the MA administered medications inside the room. This allowed the medications and biologicals to be accessible to other staff, residents, or visitors during the period the cart was unattended. The MA acknowledged in an interview that the cart should never be left unlocked or unattended and that medications should not be left out on top of the cart when unattended. The Director of Nursing (DON) confirmed that all staff are expected to keep the medication cart locked unless it is actively being used, and that staff receive regular reminders and annual competency checks regarding medication pass procedures. The facility's policy requires all medications to be stored securely in accordance with professional standards. The failure to lock the medication cart and secure medications was observed and confirmed through staff interviews and policy review.
Failure to Follow Infection Control Protocol During Medication Administration
Penalty
Summary
A medication aide failed to follow proper infection prevention and control procedures during the administration of eye drops to a resident. Specifically, the aide did not perform hand hygiene or don gloves before administering Timolol Maleate Ophthalmic Solution to the resident, nor did she wash her hands after the procedure. This was directly observed by surveyors during a medication pass. The aide later acknowledged in an interview that she should have washed her hands and worn gloves, attributing her lapse to nervousness and recognizing that not doing so could spread germs and infections. The resident involved had a history of sepsis, anxiety, myasthenia gravis, and glaucoma, and was noted to have severely impaired cognition. Facility records and policies reviewed by surveyors confirmed that staff are required to perform hand hygiene and use personal protective equipment before resident care procedures, including medication administration. The Director of Nursing confirmed that all staff had been educated on these requirements and that hand hygiene is part of annual competency checks.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to use appropriate alternatives before installing bed rails for three residents, and did not assess the residents for the risk of entrapment, review the risks and benefits with them or their representatives, or obtain informed consent prior to installation. This deficiency was identified during observations, interviews, and record reviews. The residents involved had various medical conditions, including polyosteoarthritis, chronic heart failure, and cerebral infarction, which could potentially increase their vulnerability to the risks associated with bed rail use. For Resident #1, there was no mention of bed rails in the care plan, no physician orders for their use, and no informed consent or risk assessment on file. An observation revealed that the resident was asleep with side rails in the up position. Similarly, Resident #2's records showed no care plan mention, physician orders, or informed consent for bed rails, and the resident expressed that she did not consent to their use. She also reported a past incident involving the side rails that made her nervous about sleeping in her bed. Resident #3's records also lacked documentation of bed rail use, including care plan mention, physician orders, informed consent, and risk assessment, yet observations showed the resident asleep with side rails up. Interviews with facility staff, including the VPCO, DON, and ADM, revealed that the bed rails were already on the beds when the facility was acquired and were not removed because they were used as enablers. The staff acknowledged the lack of assessments, orders, and consents, and recognized the potential risks of entrapment and injury associated with the use of bed rails without proper documentation and consent. The facility's policy emphasized the need for a person-centered approach, assessment of alternatives, and informed consent, none of which were followed in these cases.
Failure to Notify Residents of Physician Change
Penalty
Summary
The facility failed to honor the residents' right to choose their attending physician, affecting five residents. This issue arose after the facility terminated the agreement with their Medical Director and changed the attending physician without notifying the residents or their representatives. The change was effective on July 4, 2024, and the lack of communication regarding this change was evident in the interviews and record reviews conducted during the survey. Resident #1, a female with intact cognition, was not informed about the change in her primary physician. She noticed the change when a new doctor visited her, but she was not officially notified. Similarly, Resident #2's responsible party was not informed about the change in the medical director, although they were notified about the facility's change in ownership. Resident #3's responsible party also did not receive any notification about the change in the medical director or the primary physician. The facility's administration acknowledged the oversight in communication. The new administrator and other staff members, including the Director of Operations and the Director of Nursing, admitted that residents and their responsible parties should have been notified 30 days in advance of the change. However, there was no evidence that such notifications were distributed, leading to confusion and a lack of choice for the residents regarding their attending physicians.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure that medications for a resident were stored securely and properly, as required by regulations. During an observation, a medication aide was seen leaving a box of Mucinex tablets and a Baclofen tablet unsecured on top of a medication cart while she went to retrieve an additional Baclofen tablet from the medication room. This lapse in protocol left the medications unattended for approximately 4-5 minutes, although no residents were observed in the hallway during this time. The medication aide acknowledged that leaving medications unattended was against the facility's policy. Additionally, the facility did not properly dispose of medications, as evidenced by a loose Docusate sodium tablet found in a trash can in the private dining room. The Director of Nursing (DON) confirmed that medications should be disposed of in a sharps container and not in the trash. The DON also stated that leaving medications unsecured or improperly disposing of them could lead to serious consequences, such as a resident taking medication that was not theirs. Interviews with staff, including the DON and the Administrator, revealed that the facility's policy required medications to be locked in a medication cart or attended by staff. The facility's Preparation for Medication Administration policy outlined the need for lockable medication carts and proper disposal methods. However, additional policies regarding secure storage and disposal of medications were requested but not provided by the time of the survey exit.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an incident of injury of unknown sources to the state agency within 24 hours, as required by regulations. A male resident, who had been admitted less than 24 hours prior, was found on the floor with a bleeding head wound. The incident was documented by an RN, and the resident was sent to a local hospital for treatment. Despite the severity of the incident, the facility did not report it to the state agency within the mandated timeframe. The administrator was informed of the incident shortly after it occurred, but waited for corporate approval before reporting it to the state, which did not happen until the following day. Interviews with facility staff revealed that the corporate nurse was not made aware of the incident until the day after it occurred, leading to a delay in reporting. The facility's policy mandates that all incidents of abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, must be reported to the appropriate agencies within 24 hours. However, this policy was not followed in this case, resulting in a failure to comply with state and federal regulations.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 91 citations issued within 25 miles in the last 12 months — including the 10 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bryan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestview Retirement Community | 0.1 mi | ★★★★★ | 0 | 0 |
| Lampstand Nursing And Rehabilitation | 0.2 mi | ★★★★★ | 20 | 2 |
| Legacy Nursing And Rehabilitation | 0.5 mi | ★★★★★ | 5 | 0 |
| Five Points Nursing & Rehabilitation Of College St | 5.6 mi | ★★★★★ | 10 | 3 |
| Fortress Nursing And Rehabilitation | 6.4 mi | ★★★★★ | 3 | 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.