Above average — CMS composite of the measures below.
The next survey window likely opens around September 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.
Infection prevention and control was not maintained for multiple residents. A CNAT handled an ice pack from one resident’s room, then passed lunch trays and applied clothing protectors to three residents without hand hygiene. A CNA transferred a resident on EBP without a gown or gloves, and another CNA emptied a catheter bag for a resident on EBP, removed PPE, exited the room, and did not perform hand hygiene until later. The DON confirmed the hand hygiene and PPE lapses.
The facility did not ensure proper respiratory care for two residents using CPAP and nebulizer equipment. One resident with OSA had no CPAP order, no documented settings, and no orders for cleaning the mask or tubing, while staff only filled the machine with water and offered the device. Another resident with COPD had nebulizer tubing that was not changed per facility practice, and the record lacked orders to change or clean the nebulizer parts; staff and the DON confirmed the missing documentation.
A resident receiving Hospice care for cancer and a fracture had no current Hospice care plan in the chart, and CNA Hospice notes were not available to the facility. The resident said scheduled bed baths were not always provided and requested daily LE ROM exercises, but bathing documentation was inconsistent and the resident’s care plan did not reflect the ROM request. The DON confirmed the facility did not have the updated Hospice notes and was unsure which staff provided some of the baths.
Two residents were physically assaulted by a family member in the dining room, with staff witnessing the incidents and removing the residents from harm. Although facility policy required contacting police for suspected crimes, the policy lacked clear guidance and the facility did not notify law enforcement, relying instead on the wishes of the residents' POA and the administrator's judgment.
A resident reported an abuse allegation involving a CNA, which the facility failed to report to the State Agency within the required 24-hour timeframe. The resident, who had intact cognition and was receiving hospice services, alleged that a CNA threw a washcloth in their face and rolled them in a way that caused sores. The initial report was submitted late, and the five-day investigation report was also delayed.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to Enhanced Barrier Precautions (EBP) policies. A nurse did not wear a gown during wound care for a resident with a pressure injury, and a CNA applied lotion without PPE to a resident with wounds. Two residents with chronic wounds and a history of MRSA were not placed on EBP upon admission, indicating lapses in infection control practices.
The facility did not notify the State LTC Ombudsman of hospital transfers for two residents, as required. Despite policy requirements, the facility only informed the Ombudsman if a discharge was disputed or a 30-day notice was issued. This practice was confirmed by staff, even though an email from the Ombudsman indicated that notifications should be sent for unplanned discharges and transfers.
A resident with multiple diagnoses, including neuromuscular dysfunction of the bladder, was observed with their catheter tubing and drainage bag on the floor, contrary to facility policy. A CNA failed to reposition the bag, leaving it in contact with the floor, which was later confirmed as unacceptable by the DON.
A resident with a feeding tube was administered 237 mL of Jevity 1.2 instead of the 250 mL ordered by the physician. The error was observed by a surveyor and confirmed by both an LPN and a registered dietician, who acknowledged the discrepancy in the prescribed nutritional supplement volume.
Infection Prevention and Control Program Not Maintained
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for four residents. During an observation in the rehab dining room, a Certified Nursing Assistant in Training (CNAT) placed an ice pack from a resident’s room on that resident’s knee, then passed lunch trays and placed clothing protectors on three residents without completing hand hygiene between resident contacts. The CNAT later verified hand hygiene was not completed after handling the ice pack and before delivering lunch and clothing protectors, and the DON confirmed the CNAT should have completed hand hygiene between interactions. One resident had diagnoses including diabetes, localized edema, laceration of the head, asthma, and cellulitis of the left lower limb. The resident’s MDS assessment showed a BIMS score of 15 out of 15, and the care plan indicated the resident should be on appropriate isolation precautions due to a risk for infection. The facility’s infection surveillance log identified the resident as having cellulitis of the left lower extremity and being on enhanced barrier precautions (EBP). When the resident requested a transfer from recliner to wheelchair, a CNA entered the room and assisted with the transfer without donning a gown or gloves. The CNA later stated uncertainty about the resident’s EBP status, then acknowledged a gown and gloves should have been worn; the LPN and DON both verified PPE should have been used. Another resident had diagnoses including breast cancer, lung cancer, and femur fracture, with a BIMS score of 14 out of 15 and an indwelling catheter. The care plan indicated the resident was on EBP. After emptying the resident’s catheter drainage bag, a CNA removed gown and gloves in the bathroom, bagged garbage, opened the door, and exited the room without completing hand hygiene. The CNA stated the CNA was going to look for hand sanitizer in the hallway, then re-entered the room and completed hand hygiene after noting a sanitizer dispenser on the wall. The DON confirmed hand hygiene should have been completed after removing PPE and exiting the room.
Respiratory Equipment Orders and Cleaning Not Properly Documented
Penalty
Summary
The facility did not ensure appropriate respiratory care and services were provided for two residents who used respiratory equipment. R18 had diagnoses including obstructive sleep apnea, diabetes, and asthma, and a hospital discharge summary indicated R18 was to continue using a home sleep device with oxygen bled into the machine. However, R18’s medical record did not contain an order for CPAP use, did not specify settings, and did not include orders to clean the CPAP mask or tubing or to monitor oxygen saturation beyond a weekly vital signs order. Surveyors observed the CPAP machine filled with water on R18’s nightstand, along with the mask and tubing, and R18 stated staff had not cleaned the mask or tubing. Staff interviews confirmed they only filled the machine with water or offered the CPAP, and the DON stated the facility should have had orders for CPAP use and cleaning. R28 had a diagnosis of COPD and an order for ipratropium-albuterol solution via nebulizer as needed. The medical record showed nebulizer treatments were administered several times during the review period, but there were no orders to change the nebulizer tubing or clean the mask and other parts of the nebulizer. Surveyors observed the nebulizer tubing on R28’s nightstand with tape dated 9/19, and the oxygen tubing was dated 9/27. The nebulizer mask and connector were observed drying on a paper towel after a treatment. An LPN verified the record did not contain orders to change the nebulizer tubing or clean the mask, and stated the tubing should be dated when changed and the parts rinsed and left to dry after each use. The facility’s CPAP/BiPAP policy stated masks, nasal pillows, and tubing are to be cleaned daily, and the nebulizer procedure stated equipment and tubing are to be changed every seven days or according to facility protocol. Despite these written procedures, R18’s TAR did not contain CPAP orders or cleaning instructions, and R28’s TAR did not contain orders to change nebulizer or oxygen tubing. The DON confirmed the CPAP order should have been transcribed for R18 and that the nebulizer and oxygen tubing orders should have been on R28’s TAR.
Failure to Coordinate Hospice Care and Document Bathing and ROM Services
Penalty
Summary
The facility did not ensure coordination of Hospice services for one resident who was receiving Hospice care for breast cancer, lung cancer, and a femur fracture. The resident had intact cognition with a BIMS score of 14 out of 15 and made their own medical decisions. The resident’s chart contained a comfort care/end-of-life care plan indicating Hospice services, but the current Hospice care plan was not in the medical record. The facility’s contract with the Hospice agency required the Hospice to develop and update the plan of care and required the facility to coordinate personal care and nursing needs with the Hospice representative. The resident stated they did not always receive scheduled baths and requested daily lower-extremity ROM exercises, but these were not consistently provided or documented. Facility bathing records showed inconsistent documentation, including some entries for bed baths, some entries marked not applicable, and some dates with no charting. The DON confirmed the resident’s medical record did not contain updated Hospice care plan information or CNA Hospice notes because the Hospice agency had switched to computer charting and the facility was not provided the notes. The DON also confirmed the facility was unsure which staff provided some of the bed baths and acknowledged improvement was needed for offering and documenting bed baths; the resident’s care plan did not indicate a request for daily ROM exercises.
Failure to Report Suspected Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure the timely reporting of suspected abuse, neglect, or theft, specifically in relation to the reporting of a reasonable suspicion of a crime as required by section 1150B of the Act. On the date of the incident, two residents were physically assaulted by a family member in the dining room. The family member aggressively grabbed one resident, pulled them in, and struck them in the mid-section with a closed fist. The same family member also slapped another resident on the hand, grabbed their other hand, and pulled their wheelchair toward them as the resident attempted to move away. Staff witnessed these events and removed the residents from the vicinity of the family member. Despite the facility's Abuse Prevention and Response policy stating that police should be contacted if there is a suspected crime against a resident, the policy did not provide examples of reportable crimes or indicate consultation with local law enforcement regarding reporting requirements. The facility did not notify local law enforcement of the incidents, and the Nursing Home Administrator confirmed that there had been no formal discussion with law enforcement to clarify what should be reported. The decision not to report was influenced by the residents' power of attorney declining to proceed with charges, and the administrator's belief that the abuse did not warrant police notification.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Agency (SA) in a timely manner. On October 15, 2024, a resident reported to a student nurse that a Certified Nursing Assistant (CNA) had thrown a washcloth in their face while they were sleeping and had rolled them in a way that caused more sores on their buttock. The facility's policy requires that any suspected abuse be reported to the Department of Quality Assurance (DQA) immediately, but no later than 24 hours after the suspicion or notification of the abuse allegation. However, the initial report was submitted to the SA on October 16, 2024, at 11:10 AM, which was beyond the 24-hour requirement. The resident involved had been admitted to the facility with diagnoses including traumatic subdural hematoma with loss of consciousness, congestive heart failure, and cognitive communication deficit. The resident had a Brief Interview for Mental Status (BIMS) score indicating intact cognition and was receiving hospice services. The facility began an investigation on the same day the allegation was made, but the five-day investigation report was submitted late, on October 23, 2024. The Director of Nursing confirmed that both the Nursing Home Administrator and the Director of Nursing were aware of the late submission of the five-day report.
Infection Control Deficiencies in PPE Usage and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the care of four residents. Staff did not adhere to the Enhanced Barrier Precautions (EBP) policy, which requires the use of personal protective equipment (PPE) during high-contact care activities. For instance, a registered nurse did not wear a protective gown while providing wound care to a resident with a stage 3 pressure injury, despite the presence of EBP signage and a PPE cart in the room. Another resident, who had a lymphedemic cluster wound and recurrent moisture-associated skin dermatitis, was not initially placed on EBP. A certified nursing assistant was observed applying lotion to the resident's leg without wearing a gown, even though a PPE cart was later placed outside the room. The resident was unsure of the reason for the PPE cart's presence, indicating a lack of communication and adherence to the EBP policy. Additionally, two residents with significant medical histories, including a history of MRSA and chronic wounds, were not placed on EBP upon admission. One resident had a Foley catheter and a stage 4 sacral pressure injury, while another had venous ulcers and pressure-induced deep tissue damage. The Director of Nursing later confirmed that these residents should have been on EBP, but their care plans did not reflect this requirement, highlighting a gap in the facility's infection control practices.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of hospital transfers for two residents, R22 and R43, as required. R22 was transferred to the hospital on two occasions for shortness of breath, and R43 was transferred to rule out cardiac issues. In both cases, the medical records did not include copies of the transfer notices provided to the Ombudsman. The facility's policy, revised in July 2021, required notification of the Ombudsman in such cases, but this was not adhered to. The surveyor's investigation revealed that the facility only notified the Ombudsman if a discharge was disputed or if a 30-day notice was given. The Social Worker and Nursing Home Administrator confirmed this practice, despite an email from the Ombudsman indicating that notifications should be sent for unplanned discharges and transfers. The facility's failure to consistently communicate with the Ombudsman and maintain proper documentation led to the deficiency.
Inadequate Catheter Care Leading to Infection Risk
Penalty
Summary
The facility failed to ensure that a resident received appropriate catheter care to prevent urinary tract infections. The resident, who had intact cognition and multiple diagnoses including neuromuscular dysfunction of the bladder and paraplegia, was observed with their catheter tubing and drainage bag on the floor under their bed. This was contrary to the facility's policy, which required the catheter bag to be kept below the level of the bladder and off the floor to prevent infections. A Certified Nursing Assistant (CNA) checked the resident's catheter but did not reposition the bag or tubing, leaving it in contact with the floor. The Director of Nursing confirmed that this was not acceptable practice. The resident later reported that a nurse had moved the catheter bag into a wash tub, but this was after the surveyor's observation of the deficiency.
Incorrect Administration of Jevity 1.2 to Resident
Penalty
Summary
The facility failed to administer the correct amount of Jevity 1.2, a nutritional meal supplement, to a resident with a feeding tube. The resident, who had diagnoses including Alzheimer's disease, dementia, adult failure to thrive, dysphagia, and required attention to a gastrostomy tube, was observed receiving 237 mL of Jevity 1.2 instead of the 250 mL ordered by the physician. This discrepancy was noted during an observation by a surveyor, who witnessed an LPN administering the incorrect volume. Both the LPN and a registered dietician confirmed that the resident's order specified 250 mL of Jevity 1.2, and the error was acknowledged during interviews with the staff.
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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 New London
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avina Of Weyauwega | 9.8 mi | ★★★★★ | 6 | 0 |
| Manawa Com Nur Ctr | 10.7 mi | ★★★★★ | 0 | 0 |
| Brewster Village | 15.4 mi | ★★★★★ | 13 | 0 |
| Bethany Home | 17.1 mi | ★★★★★ | 2 | 0 |
| Rennes Health And Rehab Center-appleton | 17.5 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.