St. Joe Manor

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 147. Review of the facility's policy titled, Code of Dress and Personal Appearance, dated 2011, showed:- All Dining Services employees will comply with printed and posted personal hygiene and sanitation practices of this facility;- Hairnets, hair restraints, and beard guards shall be worn. [...]

Inspectors wroteBased on interview and record review, the facility failed to demonstrate evidence of maintaining an ongoing effective, comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. This had the potential to affect all residents residing in the facility. The facility's census was 147. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment decisions, including hospice election and code status decisions, were made by the resident or a legally authorized representative. This failure affected one resident (Resident #7) out of 29 sampled residents. The facility census was 147. Review of the facility policy titled, Advanced Directives, revised September 2022, showed:- The resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment, advanced directives are honored in accordance with state law and facility policy;- Prior to or upon admission of a resident, the social services director (SSD), or designee inquires of the resident, his/her family members, and/or his or her legal representative about the existence of any written, advanced directives; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital and failed to provide a copy of the bed-hold policy with the daily rate amount upon transfer to the hospital for six residents (Residents #1, #2, #4, #11, #114, and #123) out of 29 sampled residents. The facility's census was 147. Review of the facility's policy titled, Bed Holds and Returns, revised October 2022, showed: - Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies; - All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain urinary catheter (a sterile tube inserted into the bladder to drain urine) orders for one resident (Resident #15) out of three sampled residents with a urinary catheter and failed to follow physician's orders for one resident (Resident #13) out of 29 sampled residents. The facility census was 147. Review of the facility policy titled, Catheter Care, Urinary, revised August 2022, showed: - Empty the collection bag at least every eight hours; - Review and document the clinical indications for catheter use prior to inserting; - Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place; - Remove the catheter as soon as it is no longer needed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure communication forms that reflected ongoing coordination and collaboration between facility staff and the dialysis (a life-sustaining medical treatment that filters waste, toxins, and excess fluids from the blood when the kidneys have failed) staff were sent with two residents (Residents #11 and #62) out of two sampled dialysis residents on all dialysis days and failed to ensure one resident (Resident #11) had an order for dialysis. The facility's census was 147. Review of the facility's policy titled, Dialysis, dated 03/25/20, showed: - Effective immediately: Anyone going to dialysis will bring a dialysis communication form with them that has the most recent vital signs or order changes for the patient on it as well as any concerns you may have; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled Certified Nurse Aides (CNAs) received an annual performance review. The facility census was 147. Review of the facility's employee handbook, dated 12/08/23, showed:- Performance Improvement: The facility will make efforts to periodically review your work performance;- The performance improvement process will take place annually or as business needs dictate;- You may specifically request that your supervisor assist you in developing a performance improvement plan at any time. The facility did not provide a policy related to annual performance reviews.1. Review of CNA K's personnel file showed:- Hire date of 04/09/25;- No documentation of an annual performance review.2. Review of CNA L's personnel file showed:- Hire date of 05/08/25;- No documentation of an annual performance review. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP - precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO - microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for two residents (Residents #13 and Resident #83) out of two sampled residents. The facility failed to follow proper infection control practices during incontinent care for two residents (Residents #1 and #154) out of three sampled residents. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, and side rails as part of a regular maintenance program for three residents (Residents #52, #96, and #154) out of 29 sampled residents with side rails. The facility's census was 147. Review of the facility's policy titled, Bed Safety and Bed Rail, revised September 2025, showed: - The resident's sleeping environment is evaluated by the interdisciplinary team; - Consideration is given to the resident's safety. Medical conditions, comfort and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; - Bed frames, mattresses, and bed rails are checked for compatibility and size prior to use; - Bed dimensions are appropriate for the resident's size; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to include the actual hours, and total hours worked per shift for licensed and unlicensed staff responsible for resident care and failed to include the daily census for four of the four observed days. The facility census was 147. Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised August 2022, showed:- Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents;- Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following:a. The name of the facility;b. The current date;c. The resident census for the beginning of the shift for which the information is posted;d. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for eleven residents (Resident #18, #25, #28, #34, #44, #49, #53, #81, #111, #126, and #131) out of 28 sampled residents and one resident (Resident #139) outside the sample. The facility's census was 139. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, revised October 2022, showed: - Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for four residents (Resident #18, #34, #44, and #53) out of 28 sampled residents. The facility's census was 139. Review of the facility's policy titled, Bed Holds and Returns, revised October 2022, showed: - Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies; - All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Resident #41 and #131) out of 28 sampled residents and two residents (Resident #40 and #138) outside the sample. The facility's census was 139. The facility did not provide a policy regarding MDS accuracy. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual showed: - Section J1400 should be coded yes if the resident is receiving hospice services; - Section N0300 should state the number of days during the 7-day look-back period that any type of injection was received; - Section N0350A should state the number of days during the 7-day look-back period that insulin injections were received. 1. Review of Resident #40's medical record showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for four residents (Resident #31, #41, #55 and #111) out of 28 sampled residents. The facility's census was 139. Review of the facility's Comprehensive Person-Centered Care Plan Policy, last revised March 2022, showed: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a a comprehensive, person-centered care plan for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; [...]

Inspectors wroteBased on interview and record review, the facility failed to update and revise care plans with specific interventions to meet individual needs for five residents (Resident #1, #6, #18, #34, and #126) out of 28 sampled residents. The facility's census was 139. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised March 2022, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The interdisciplinary team reviews and updates the care plan: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide consistent resident care for activities of daily living (ADLs) when the residents went an extended amount of time without showers for two residents (Resident #24 and #55) out of three sampled residents. The facility's census was 139. The facility did not provide a facility regarding shower frequency. 1. Review of Resident #24's medical record showed: - An admission date of 11/29/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an order for oxygen administration and failed to ensure a physician's order for bilevel positive airway pressure (BIPAP - a noninvasive ventilation device that helps people breathe by delivering pressurized air into the airways) included settings. This affected one resident (Resident #41) out of two sampled residents. The facility's census was 139. Review of the facility's policy titled, CPAP (continuous positive airway pressure)/BIPAP Support, revised March 2015, showed in preparation for BIPAP, review the physician's order to determine the oxygen concentration and flow, and the PEEP (positive end-expiratory pressure, settings) pressure for the machine. Review of Resident #41's medical record showed: - admission date of 09/12/24; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 35 opportunities with three errors made, for an error rate of 8.57%, which affected three residents (Residents #32, #102 and #133) out of seven sampled residents. The facility's census was 139. Review of the facility's policy titled, Insulin Administration, revised September 2014, showed: - The type of insulin, dosage requirements, strength, and method of administration must be verified before administration; - The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery systems prior to their use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices and implement Enhanced Barrier Protections (EBP) during foley catheter (a thin, flexible tube inserted into the bladder to drain urine) care for one resident (Resident #31) out of 28 sampled residents. The facility's census was 139. Review of the facility's Handwashing/Hand Hygiene Policy, dated 2001, showed: - All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections; - All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors; - Hand hygiene products and supplies are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices during perineal care for one resident (Resident #1) out of one sampled resident. The facility's census was 137. Review of the facility's Perineal Care Policy, dated February 2018, showed: - Purpose of procedure is to provide cleanliness and comfort to the resident, to prevent infections, skin irritation and to observe the skin condition; - Place equipment on bedside stand and arrange to be easily reached; - Wash hands thoroughly, dry and put on gloves; - Wet washcloth and apply skin cleanser; - Wash perineal area from front to back; - Turn resident to side and wash rectal area thoroughly, wiping from the base of labia towards and extending over the buttocks; - Rinse and dry thoroughly; - Discard disposable items, remove gloves and wash hands; [...]

Inspectors wroteBased on interview and record review, facility staff failed to report an allegation of resident-to-resident abuse to the state licensing agency officials as required for two residents (Resident #1 and #2) out of four sampled residents. Resident #2 pushed Resident #1 which caused him/her to fall and sustain a head injury that required two staples to the left forehead and a skin tear to his/her left elbow. The facility census was 141. Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, last updated 09/22, showed: - Verbal or written notification of an incident or suspicion of abuse or neglect to the immediate supervisor, charge nurse, the Director of Nurses (DON), the Social Service Designee (SSD) or the Administrator; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately assess the use of bed rails for 12 residents (Resident #6, #23, #25, #26, #27, #47, #52, #60, #68, #88, #90, and #91) of 28 sampled residents. The facility census was 141. Review of the Federal Drug Administration (FDA) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013, showed seven different potential zones of entrapment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to conduct regular inspections of all bed frames, mattresses and side rails as part of a regular maintenance program for 12 residents (Residents #6, #23, #25, #26, #27, #47, #52, #60, #68, #88, #90, and #91) out of 28 sampled residents. The facility's census was 141. Review of the Federal Drug Administration (FDA) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 141. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - Clean, sanitary and orderly environment; - Pleasant, neutral scents. Observation on 01/10/24 at 11:17 A.M., of the 200 Hall shower room showed broken tiles with rough edges surrounding the floor drain threshold for the shower entrance. Observation on 01/11/24 at 11:55 A.M., of room [ROOM NUMBER]'s bathroom sink showed water dripping from the drain into a plastic wash basin sitting on the floor. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer to the hospital for three residents (Residents #23, #35 and #52) out of 28 sampled residents. The facility census was 141. The facility did not provide a policy regarding a facility-initiated transfer. 1. Review of Resident #23's medical record showed: - Resident transferred to the hospital for medical evaluation on 11/28/23, and readmitted to the facility on [DATE]; - No documentation of a letter notifying the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. 2. Review of Resident #35's medical record showed: - Resident transferred to the hospital for medical evaluation on 10/16/23, and readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and/or resident representative of the bed hold policy at the time of transfer to the hospital for three residents (Resident #23, #35 and #52) out of 28 sampled residents. The facility's census was 141. Review of the facility's policy titled, Bed Hold Policy, undated, showed: - Purpose is to notify all residents and/or resident's representative of the bed hold policy for the facility; - If the resident or representative wants to hold the bed, a signed authorization must be obtained with each discharge, these forms are located in the business office; - Upon discharge, the nursing supervisor will re-inform the resident and/or responsible party of the bed hold policy. The designee will follow up the next business day to assure resident and/or responsible party understands the requirements of the bed hold policy; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document an accurate Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, for two residents (Resident #23 and #60) out of 28 sampled residents. The facility's census was 141. Review of the facility's policy titled, Electronic Transmission of the MDS, revised November 2019, showed the MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data. 1. Review of Resident #23's medical record showed: - admission date of 03/24/23; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for three residents (Resident #25, #26, and #52) out of 28 sampled residents. The facility census was 141. Review of the facility's policy titled, Comprehensive Care Plan, revised December 2016, showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs will be developed and implemented for each resident. 1. Review of Resident #25's medical record showed: - An admission date of 08/25/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician's wound care orders for four residents (Resident #26, #58, #95, and #116) out four sampled residents with wounds. The facility census was 141. The facility did not provide a policy regarding following physician orders. 1. Review of Resident #26's medical record showed: - admission date of 11/15/23; - Diagnoses of chronic non-pressure ulcer (non-healing wound not caused by pressure) of left and right lower leg, stage two pressure ulcer (shallow open injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left buttock, and unstageable (unable to see the wound bed) pressure ulcer of the sacrum (triangular bone at the base of the spinal column). Review of the resident's wound care documentation showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADLs) when residents did not receive a minimum of two showers per week and preferences were not acknowledged for eight residents (Resident #1, #6, #19, #23, #51, #52, #68 and #123) out of 28 sampled residents. The facility census was 141. Review of the facility's policy titled, Shower, revised 02/03/22, showed: - All residents will be offered and given a shower on their scheduled shower days unless the resident refuses or a staffing emergency; - If a full shower is unable to be given, a bed bath will be offered and a full shower given as soon as possible; - If an alert resident declines a bed bath and only wants a shower, the shower will be completed within 48 hours. 1. Review of Resident #1's medical record showed: - admission date of 05/26/2022; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for three out of three observed medication carts. This had the potential to affect all residents. The facility census was 141. Review of the facility's policy titled, Controlled Substances, dated April 2019, showed: - The facility will follow all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances; - Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift; - Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure vials of Insulin Glargine (medication to control high blood sugar with diabetes) and Tubersol (a solution used during a tuberculosis test) were dated when opened. This had the potential to affect all residents. The facility's census was 141. Review of the facility's policy titled, Storage of Medications, revised November 2020, showed: - The facility stores all drugs and biologicals in a safe, secure, and orderly manner; - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; - Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the manufacturer's recommendations for Tubersol, revised September 2015, showed the medication to be discarded 30 days after opened. [...]