St Joseph's Manor

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jan 9, 2026

  Based on observation and staff interview, it was determined that the facility failed to store food in a sanitary manner in the main kitchen, two of seven resident pantries (Green Valley and the Meadows), and one of seven resident dining service areas (Green Valley). Findings include:Observation during the tour of the main kitchen, the [NAME] Valley resident serving area, and the [NAME] Valley resident pantry on January 6, 2026, beginning at 10:15 a.m., revealed the following: In the main kitchen, the floor mixer was in use and had areas of peeled paint on the front and top of the motorhead above the mixing bowl. In the [NAME] Valley resident dining service area refrigerator, there were four cups of yogurt with a use-by date of January 2, 2026. […]

• No harm, potential for more than minimal, widespreadF812Feb 13, 2025

  Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to store and serve foods in a sanitary manner in the dietary department to prevent the potential for foodborne illness. Findings include: Review of the facility policy entitled Food Storage, last reviewed March 8, 2024, revealed that food was to be stored immediately after receipt and maintained in a manner to prevent damage, spoilage, infestation, or bacterial contamination. Observation during the initial kitchen tour on February 11, 2025, at 10:00 a.m., revealed the following: There was debris on the bottom of the stand up ice cream freezer. There were four bins of dry goods that included white rice, flour, thickened liquid product, sugar and brown rice. […]

• No harm, potential for more than minimal, widespreadF838Feb 13, 2025

  Based on review of the facility assessment and dietary policies and procedures, it was determined that the facility failed to implement the facility wide assessment to ensure that there was an inventory of resources. These resources included an adequate supply of sustenance, food and beverages, in the event of an emergency/disaster for residents and staff. Findings include: Review of the facility assessment dated [DATE], revealed that the facility was to maintain and manage a documented inventory of resources that may be needed in an emergency. There was a reference in the facility assessment to the facility emergency preparedness plan. […]

• No harm, potential for more than minimal, patternF697Apr 2, 2021

  Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately assess and manage pain, and failed to attempt non-pharmacological interventions to alleviate pain prior to or in conjunction with the administration of pain medication prescribed on an as needed basis for four of 37 sampled residents. (Residents 92, 118, 144, 161) Findings include: Review of the facility policy entitled Pain Assessment Guide, dated June 24, 2020, revealed that standardized pain assessment tools such as a ten-point pain numeric pain rating scale (0 indicating no pain and 10 indicating the worst pain imaginable), were to be completed with results documented daily on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF641Jan 9, 2026

  Based on clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for two of 36 sampled residents. (Residents 4 and 13)Findings include: Clinical record review revealed that Resident 4 had diagnoses that included fibromyalgia (widespread body pain and fatigue) and depression. Review of the MDS assessment dated [DATE], revealed that Sections P (Restraints and Alarms) incorrectly indicated that the resident used a restraint, but less than daily. There was no documentation in the clinical record that indicated Resident 4 used any type of restraint during the review period. Clinical record review revealed that Resident 13 had diagnoses that included peripheral vascular disease and chronic embolism. […]