St. Joseph Manor Health Care Inc

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure care was provided to one Resident (#5), of 21 sampled residents, in accordance with professional standards of practice. Specifically, the facility failed to follow physician's orders to hold Resident #5's midodrine (prescription medication used to treat low blood pressure) per ordered parameters.

Inspectors wroteBased on records reviewed, document review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) while providing care to one Resident (#107), who was on contact precautions, to prevent the potential spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician or nurse practitioner (NP) was notified timely of critical urinalysis culture & sensitivity (C&S) report for one Resident (#69), out of a total sample of 21 residents. Specifically, for Resident #69, their urinalysis C&S final report was reviewed with the NP on 12/1/25, four days after it was received in the facility on 11/27/25, resulting in Resident #69 receiving six doses of Macrobid (antibiotic) 100 milligrams (mg) before it was discontinued for a more effective antibiotic.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications were stored and labeled in accordance with currently accepted professional standards. Specifically, the facility failed to ensure staff properly labeled and stored all medications in one of three medication carts reviewed.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure the main kitchen, main dining room steam table, and basement food storage area were clean and maintained in a sanitary manner to prevent potential food contamination; and 2. Maintain two of three kitchenettes in a clean and sanitary condition, and ensure food stored is not expired and stored at appropriate temperatures to prevent foodborne illness.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Perform a COVID-19 related investigation and conduct contact tracing to prevent, to the extent possible, the onset and spread of infection; and 2. Maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections.

Inspectors wroteBased on record review and interview, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for one Resident (#98), out of a total sample of 22 residents. Specifically, the facility failed to ensure the Foley catheter was assessed for removal as soon as possible after returning from the hospital and failed to ensure he/she followed up with Urology as recommended.

Inspectors wroteBased on interview and observation, the facility failed to maintain a clean environment and in good repair in 5 bedrooms (rooms 214, 215, 216 , 217 and 222) on one resident unit ([NAME] II).

Inspectors wroteBased on observation, record review and interview, the facility failed to implement the plan of care for one Resident (#86), out of a total of 24 sampled residents. Specifically, the facility failed to ensure Resident #86's call light was within reach.

Inspectors wroteBased on record review and interviews, the facility failed to revise the plan of care related to dialysis for one Resident (#72), out of a total sample of 24 residents.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for two Residents ( #22 and #17) out of a total sample of 24 residents. Specifically, the facility failed to: 1. For Resident #22, ensure nursing staff administered Coumadin (anticoagulant) for Resident #22, who was recently diagnosed with a deep vein thrombosis (DVT). 2. For Resident #17, administer medications in accordance with standards of practice, and not crush enteric coated (EC) and extended release (ER) medications.

Inspectors wroteBased on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when one out of two nurses observed made three errors out of 29 opportunities resulting in a medication error rate of 10.34%. Those errors impacted two Residents (#59 and #17), out of 4 residents observed.

Inspectors wroteBased on observations, policy review and interviews the facility failed to to ensure that 1. medications were stored securely on one unit and 2. Medications were not left on the medication cart unsecured.

Inspectors wroteBased on observation, policy review and interview the facility failed to ensure food items were stored and labeled in accordance with professional standards for food service safety in the kitchen.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to maintain accurate medical records for one Resident (#59) out of a total sample of 24 residents.