Saint Joseph Care Center

In the surveyor’s words

From the most serious findings on record at Saint Joseph Care Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 5, 2026

  Based on observation, medical record review, staff and representative interview, and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure monitoring and assessments were completed timely and appropriately for pressure ulcers and wound care was completed as ordered. This affected two residents (#5 and #61) of three reviewed for pressure wounds. The facility census was 57. Actual Harm occurred beginning on 11/04/25 to Resident #5, who was cognitively impaired, at risk for pressure ulcer development and required staff assistance for activities of daily living care, when the resident was identified to have moisture associated skin damage (MASD) to the coccyx that went unassessed and unmonitored… […]

• Actual harm, isolatedF689Apr 21, 2025

  Based on closed record review, review of a facility fall investigation, interviews and review of the facility policies, the facility failed to ensure adequate, individualized and effective fall risk interventions were in place to prevent a fall with injury for Resident #60, a resident at risk for falls. This affected one resident (#60) of three residents reviewed for falls. The facility census was 51. Actual Harm occurred on 03/10/25 when Resident #60 sustained an unwitnessed fall out of bed resulting in a fractured left arm, a laceration to the right side of her forehead, and a bruise to her right cheek. Prior to the incident, the resident had been having behaviors which staff identified as terminal agitation. […]

• No harm, potential for more than minimal, widespreadF727Jan 5, 2026

  Based on review of the CASPER Report 1705D (Staffing Report) for quarter three of fiscal year 2025 ([DATE]- [DATE]), review of facility nursing schedules, facility daily staffing report postings, and interview with staff, the facility failed to ensure eight consecutive hours of registered nursing coverage per day. This had the potential to affect all residents residing in the facility. The facility census was 57. Findings include:Review on [DATE] of the Centers for Medicare and Medicaid (CMS) CASPER Report 1705D for quarter three of fiscal year 2025 ([DATE]- [DATE]) revealed no Registered Nurse (RN) coverage for more than eight consecutive hours on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].Review on [DATE] of the facility daily nursing schedules revealed no RN assigned/scheduled… […]

• No harm, potential for more than minimal, widespreadF814Jan 5, 2026

  Based on observation, staff interview, and policy review, the facility failed to maintain a clean and sanitary dumpster area. This had the potential to affect all residents residing in the facility. The facility census was 57.Findings include:Observation on 12/29/25 at 8:26 A.M. with Dietary Manager (DM) #74 revealed significant unbagged debris mostly consisting of used gloves surrounding the dumpster. There were also various furniture items and housewares piled up along the fence surrounding the dumpster. Interview on 12/29/25 at 8:28 A.M. with Dietary Manager #74 confirmed the area was not kept clean and free of debris. Review of the facility policy Waste Disposal (undated) revealed trash bags would be sealed prior to removing them from the facility. […]

• No harm, potential for more than minimal, widespreadF812Mar 13, 2024

  Based on observation, interview, and policy review the facility failed to ensure foods were labeled, dated, and discarded when expired. This had the potential to affect all 51 residents in the facility. Findings Include: Observation of the main kitchen and resident refrigerators on [DATE] starting at 8:59 A.M. with Dietary Manager (DM) #235 revealed the following areas of concern: In the dry storage area in the main kitchen, there was an expired case of tortillas dated [DATE]. In the juice and supplement cooler in the main kitchen, there were multiple containers of yogurt and juice that were out of date. On the Division One unit, there were two containers of takeout food without a date or name. On the Rehab unit, there was takeout with Resident #26's name and a date of [DATE]. […]