St Joseph Manor Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at St Joseph Manor Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Jan 29, 2024

  Based on observation, interview and record review, facility staff failed to follow physician's order for wound treatment for one resident's (Resident #322) Stage 4 pressure ulcer (a full thickness tissue loss with exposed bone, tendon and muscle caused by prolonged pressure to a bony area) on the left Ischium (the bottom of the pelvic bone), when facility staff used a bordered gauze dressing to cover Resident 322's wound instead of a Tegaderm dressing, when facility staff packed the resident's wound with gauze instead of Aquacel Ag ribbon, when facility staff failed to reposition the resident every two hours, and when facility staff failed to ensure the resident was not setting in a chair for longer than two hours. […]

• Actual harm, isolatedF600Jun 25, 2026

  Based on interview and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse when a facility staff member physically forced the resident into his/her room. Upon assessment, the resident was had burst blood vessel on his/her left thumb. The facility census was 65.On 6/25/26, the Administrator was notified of the past noncompliance incident which occurred on 6/18/26. On 6/18/26, facility administration was notified of an allegation of staff to resident abuse, an investigation immediately began and corrective actions were implemented to include: Assessment of the Resident, suspension of the accused staff member, interviews with other residents for indications of abuse, and mandatory in-service training for all staff on abuse, dignity… […]

• Actual harm, isolatedF600May 12, 2026

  Based on observations, interviews and record review, the facility failed to keep four residents (Residents #1, #2, #3, and #4) free from resident-to-resident physical abuse, resulting in injury when Resident #1 scratched Resident #2 on the neck and Resident #2 hit Resident #1 on the cheek causing redness. On a separate occasion Resident #3 scratched Resident #4's fingers. Facility census was 68.Review of the facility's Abuse Prevention Program policy, dated 2001, showed:-Our residents have the right to be free from abuse;-This includes but is not limited to freedom from verbal, mental, or physical abuse;-As part of the resident abuse preventions, the administration will protect residents from abuse by anyone, including, but not necessarily limited to other residents; -Develop and implement… […]

• Actual harm, isolatedF600Feb 22, 2024

  Based on interviews and record review, the facility failed to keep one resident (Resident #1) free from verbal and physical abuse. Certified Nurse Aide (CNA) A engaged in a verbal altercation with Resident #1 which escalated to CNA A pushing the resident from his/her wheelchair. The facility census was 67. Review of the facility's policy on Abuse Prevention, dated December 2016, showed: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. […]

• Actual harm, isolatedF697Jan 29, 2024

  Based on observation, interview, and record review, the facility failed to address pain for one resident (Resident #322) who had a pressure ulcer to the left buttocks, impaired mobility, and was dependent on staff for all activities of daily living. The facility staff failed to assess the resident's pain and document the resident's pain when the resident voiced pain, and failed to administer pain medication to the resident. The resident repeatedly stated, my butt sore and ow, with facial grimacing. […]