Deficiencies (last 8 years)
Deficiencies (over 8 years)
14.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
162% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
4% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 9
Deficiencies: 1
Date: Sep 18, 2025
Visit Reason
The document is a plan of correction following a deficiency related to fire extinguisher maintenance and inspection at St. Joe Manor.
Findings
The facility failed to ensure annual inspection and maintenance of two fire extinguishers, with one extinguisher showing a gauge indicating recharge was needed. The deficiency had the potential to affect all nine residents.
Deficiencies (1)
19 CSR 30-85.022(3)(D) Fire Extinguishers UL/FM. The facility failed to ensure fire extinguishers were inspected and maintained annually, with one extinguisher showing a gauge in the red indicating recharge was needed.
Report Facts
Facility census: 9
Inspection Report
Plan of Correction
Census: 139
Deficiencies: 9
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident transfer/discharge notices, bed-hold policies, accuracy of assessments, comprehensive care plans, infection control, medication administration, and other care standards at St Joe Manor.
Findings
The facility was found deficient in notifying residents and their representatives in writing about transfers or discharges, providing written information on bed-hold policies, documenting accurate Minimum Data Set (MDS) assessments, developing and implementing comprehensive care plans, maintaining infection control practices, and ensuring medication error rates were below 5 percent. Several residents' medical records lacked documentation of required notifications and care plan updates.
Deficiencies (9)
F623 Notice Requirements Before Transfer/Discharge. The facility failed to notify residents and their representatives in writing of transfers or discharges for eleven sampled residents and one non-sampled resident.
F625 Notice of Bed Hold Policy Before/Upon Transfer. The facility failed to provide written information on bed-hold policy to residents or their representatives for four sampled residents at the time of transfer.
F641 Accuracy of Assessments. The facility failed to document accurate Minimum Data Set assessments for two sampled residents.
F656 Develop/Implement Comprehensive Care Plan. The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for four sampled residents.
F657 Care Plan Timing and Revision. The facility failed to update and revise care plans with specific interventions to meet individual needs for five sampled residents.
F677 ADL Care Provided for Dependent Residents. The facility failed to provide consistent resident care for activities of daily living when residents went an extended time without showers for two sampled residents.
F695 Respiratory/Tracheostomy Care and Suctioning. The facility failed to obtain an order for oxygen administration and ensure proper respiratory care for one sampled resident.
F759 Free of Medication Error Rates 5 Percent or More. The facility failed to maintain a medication error rate of less than five percent, with an error rate of 8.57% affecting three residents.
F880 Infection Prevention & Control. The facility failed to maintain proper infection control practices including hand hygiene, use of enhanced barrier precautions, and annual infection prevention program review.
Report Facts
Facility census: 139
Medication error rate: 8.57
Medication error opportunities: 35
Medication errors: 3
Inspection Report
Routine
Census: 139
Deficiencies: 9
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident transfers, care planning, medication administration, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in timely notification of resident transfers to hospitals, providing written bed hold policy information, accurate Minimum Data Set (MDS) assessments, comprehensive and updated care plans, consistent assistance with activities of daily living including showering, safe respiratory care including proper orders for oxygen and BIPAP, medication administration with insulin pen priming errors, and infection control practices during catheter care.
Deficiencies (9)
Failed to notify residents and/or representatives in writing of hospital transfers for multiple residents.
Failed to provide written information on bed hold policy at time of hospital transfer for several residents.
Failed to document accurate Minimum Data Set (MDS) assessments for several residents.
Failed to develop and implement complete care plans with specific interventions for individual resident needs.
Failed to update and revise care plans timely to reflect current resident conditions.
Failed to provide consistent resident care for activities of daily living, including showering, resulting in extended periods without showers for some residents.
Failed to obtain physician orders for oxygen administration and BIPAP settings for a resident using these therapies.
Failed to maintain medication error rate below 5%, with insulin pen priming errors observed during administration.
Failed to maintain proper infection control practices and implement Enhanced Barrier Protections during foley catheter care.
Report Facts
Residents affected by transfer notification deficiency: 12
Residents affected by bed hold policy notification deficiency: 4
Medication administration opportunities: 35
Medication administration errors: 3
Medication error rate: 8.57
Number of falls for Resident #34: 12
Shower opportunities missed for Resident #24 in December 2024: 6
Shower opportunities missed for Resident #24 in January 2025: 6
Shower opportunities missed for Resident #55 in December 2024: 7
Shower opportunities missed for Resident #55 in January 2025: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Failed to prime insulin pens prior to administration |
| CMT B | Certified Medication Technician | Failed to prime insulin pens prior to administration |
| CNA E | Certified Nursing Aide | Failed to perform proper hand hygiene and don gown during foley catheter care |
| RN C | Registered Nurse | Provided information on transfer notification and shower schedule |
| ADON | Assistant Director of Nursing | Provided information on transfer notification, shower schedule, and medication administration expectations |
| DON | Director of Nursing | Provided information on transfer notification, shower schedule, medication administration, and infection control expectations |
| Administrator | Provided information on transfer notification, shower schedule, medication administration, and infection control expectations |
Inspection Report
Life Safety
Census: 139
Deficiencies: 7
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to meet several fire safety requirements including self-closing devices on doors to hazardous areas, maintenance of cooking facilities, sprinkler system maintenance, portable fire extinguisher inspections, smoking regulations, use of portable space heaters, and electrical equipment wiring. These deficiencies potentially affected all residents and staff.
Deficiencies (7)
K223 Doors with Self-Closing Devices: The facility failed to ensure doors to hazardous areas had self-closing devices installed, as observed on the laundry room door to the exit corridor.
K324 Cooking Facilities: The kitchen failed to maintain a clean environment free of greasy, flammable buildup around the stove area, including greasy kitchen hood, filters, walls, and fire alarm pull station.
K353 Sprinkler System Maintenance: The facility failed to maintain the sprinkler system properly, with blocked sprinkler heads and accumulation of lint and dust, and missed monthly inspections.
K355 Portable Fire Extinguishers: The facility failed to maintain monthly inspections of fire extinguishers, including the kitchen hood suppression system.
K741 Smoking Regulations: The facility failed to maintain smoke areas free from fire hazards, with cigarette butts scattered in the designated smoking area.
K781 Portable Space Heaters: The facility failed to restrict the use of space heaters, with two space heaters observed in use by laundry staff.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to restrict use of temporary wiring and extension cords, with multiple violations including a refrigerator plugged into a household extension cord and extension cords powering Christmas lights.
Report Facts
Facility census: 139
Date of survey: Feb 13, 2025
Plan of correction completion date: Mar 30, 2025
Inspection Report
Plan of Correction
Census: 137
Deficiencies: 2
Date: Nov 26, 2024
Visit Reason
The visit was a state survey conducted to assess infection prevention and control practices at St Joe Manor.
Findings
The facility failed to maintain infection control practices during perineal care for one resident, specifically Resident #1. Observations and interviews revealed staff did not follow proper hand hygiene and enhanced barrier precautions.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to maintain infection control practices during perineal care for one resident, including improper hand hygiene and failure to use enhanced barrier precautions.
A4086 Infection Control/Communicable Disease: The facility failed to use acceptable infection control procedures to prevent the spread of infection, violating Missouri state regulations.
Report Facts
Census: 137
Completion date: Jan 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sharon Greco | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Routine
Census: 137
Deficiencies: 1
Date: Nov 26, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control practices, specifically during perineal care for a resident with a Peripherally Inserted Central Catheter (PICC).
Findings
The facility failed to maintain proper infection control practices during perineal care for one resident, including failure to wash hands before and after care and improper use of Enhanced Barrier Precautions (EBP) for a resident with a PICC line. Staff interviews confirmed lapses in following the facility's infection control policies.
Deficiencies (1)
Failure to maintain infection control practices during perineal care for one resident, including not washing hands before and after care and improper use of Enhanced Barrier Precautions.
Report Facts
Census: 137
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Aide | Named in infection control deficiency related to perineal care |
| CNA B | Certified Nursing Aide | Named in infection control deficiency related to perineal care |
| LPN C | Licensed Practical Nurse | Provided interview regarding proper use of Enhanced Barrier Precautions |
| Administrator | Interviewed regarding expectations for infection control practices | |
| Director of Nursing | Interviewed regarding expectations for infection control practices | |
| Assistant Director of Nursing | Interviewed regarding expectations for infection control practices |
Inspection Report
Plan of Correction
Census: 141
Deficiencies: 2
Date: Aug 20, 2024
Visit Reason
The inspection was conducted in response to allegations of resident-to-resident abuse involving two residents, including a fall and injury caused by one resident pushing another.
Complaint Details
Complaint #MO240165 was investigated regarding a resident-to-resident altercation where Resident #2 pushed Resident #1 causing injury. The complaint was substantiated based on the facility's failure to report the incident.
Findings
The facility failed to report an allegation of resident-to-resident abuse to the state licensing agency as required. Resident #1 sustained injuries from a fall caused by Resident #2 pushing him/her, and the facility did not report the incident timely.
Deficiencies (2)
F609: The facility did not report allegations of resident-to-resident abuse involving injuries within the required timeframe to the state licensing agency. Resident #1 sustained a head injury after Resident #2 pushed him/her, but the incident was not reported as required by policy.
A8025: The administrator or employee failed to immediately report suspected abuse or neglect to the Department of Health and Senior Services as required. This regulation was not met as evidenced by the F609 deficiency.
Report Facts
Facility census: 141
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 1
Date: Aug 20, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of resident-to-resident abuse involving two residents.
Complaint Details
Complaint #MO240165. The complaint involved failure to report a resident-to-resident altercation that resulted in injury. The investigation found no injuries observed at the time for Resident #1, injuries to Resident #2's face and left elbow, and an un-witnessed fall. The facility did not report the incident to the state licensing agency as required.
Findings
The facility staff failed to report an incident where Resident #2 pushed Resident #1, causing a fall that resulted in a head injury requiring staples and a skin tear. The facility did not notify the state licensing agency as required by policy.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Facility census: 141
Date of incident: Aug 16, 2024
Date of admission: Oct 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DON) | Interviewed and stated she was told by the state licensing agency that reporting was not required unless harm occurred | |
| Administrator | Interviewed and stated expectation that resident-to-resident altercation incidents be reported to the state licensing agency |
Inspection Report
Life Safety
Census: 141
Deficiencies: 2
Date: Jan 11, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to ensure full and empty oxygen cylinders were adequately separated as required by NFPA 99, posing a potential delay in staff selection of oxygen cylinders during an emergency. No deficiencies were found in the emergency preparedness portion of the survey.
Deficiencies (2)
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to ensure full and empty oxygen cylinders were adequately separated as required by NFPA 99, risking confusion during emergencies.
A2010 Oxygen Storage: The facility did not use permanent racks or fasteners to prevent accidental damage or dislocation of oxygen cylinders, violating NFPA 99 standards.
Report Facts
Facility census: 141
Inspection Report
Routine
Census: 141
Deficiencies: 11
Date: Jan 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment; failure to notify residents and representatives of hospital transfers and bed hold policies; inaccurate resident assessments; incomplete care plans; failure to follow physician wound care orders; inadequate assistance with activities of daily living; improper use and assessment of bed rails; failure to reconcile narcotics at shift changes; and failure to label and date opened medication vials.
Deficiencies (11)
Failed to provide a safe, clean, and comfortable homelike environment with issues such as broken tiles, leaking sinks, foul odors, and pest infestation.
Failed to notify residents and/or representatives in writing of facility-initiated hospital transfers for three residents.
Failed to notify residents and/or representatives in writing of the bed hold policy at the time of hospital transfer for three residents.
Failed to document accurate Minimum Data Set (MDS) assessments for two residents.
Failed to implement care plans with specific interventions for three residents.
Failed to follow physician wound care orders for four residents with wounds, resulting in missed treatments.
Failed to provide adequate assistance with activities of daily living, including missed showers and unacknowledged resident preferences for eight residents.
Failed to appropriately assess and document informed consent and entrapment risk for bed rail use for 12 residents.
Failed to reconcile narcotics at each shift change for three medication carts.
Failed to label and date opened vials of Insulin Glargine and Tubersol in medication storage.
Failed to conduct regular maintenance assessments and entrapment risk assessments for bed frames, mattresses, and side rails for 12 residents.
Report Facts
Facility census: 141
Missed showers: 25
Missed showers: 18
Missed showers: 17
Missed showers: 12
Missed showers: 7
Missed showers: 14
Missed wound treatments: 17
Missed wound treatments: 27
Missed wound treatments: 14
Missed wound treatments: 20
Missed wound treatments: 10
Missed wound treatments: 10
Missed wound treatments: 6
Missed wound treatments: 7
Missed wound treatments: 8
Missed wound treatments: 7
Missed wound treatments: 4
Missed wound treatments: 3
Missed wound treatments: 3
Missed wound treatments: 6
Missed wound treatments: 9
Missed wound treatments: 17
Missed wound treatments: 10
Missed wound treatments: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Interviewed regarding narcotic reconciliation and medication vial dating |
| RN B | Registered Nurse | Interviewed regarding narcotic reconciliation and medication vial dating |
| Administrator | Interviewed regarding expectations for resident care, bed rails, narcotic reconciliation, and medication vial dating | |
| Certified Nursing Assistant C | CNA | Interviewed regarding maintenance requisition process |
| Social Services Designee I | Interviewed regarding transfer notification and bed hold policy | |
| MDS Coordinator | Interviewed regarding MDS assessment accuracy and care plan expectations | |
| Licensed Practical Nurse D | LPN | Interviewed regarding wound care |
| Registered Nurse A | RN | Interviewed regarding wound care and skin assessments |
| Director of Nursing | Interviewed regarding wound care expectations | |
| Pharmacy Consultant | Interviewed regarding narcotic reconciliation expectations | |
| Assistant Director of Nursing | ADON | Interviewed regarding narcotic reconciliation and bed rail use |
| Maintenance Director | Interviewed regarding entrapment assessments for side rails | |
| Care Plan/MDS Coordinator | Interviewed regarding bed rail care plan documentation |
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 1
Date: Oct 24, 2023
Visit Reason
The document is a plan of correction submitted by St Joe Manor following a deficiency cited related to food temperature during meal service.
Findings
The facility failed to maintain food at a safe temperature during meal service, resulting in meals being served cold to residents. The facility did not have a policy on food temperature control and residents reported food was often cold when served.
Deficiencies (1)
19 CSR 30-87.030(34) Food-120 Degrees/Above, 45 Degrees/Below: The facility failed to maintain food at a sufficient temperature during meal service, serving meals at unsafe temperatures. The facility did not provide a policy on food temperature control.
Report Facts
Resident census: 35
Food temperature: 114.6
Food temperature: 105.1
Inspection Report
Plan of Correction
Census: 137
Deficiencies: 1
Date: Dec 20, 2022
Visit Reason
The inspection was conducted to investigate and document deficiencies related to misappropriation and exploitation of a resident's property at the facility.
Findings
The facility failed to ensure one resident was free from misappropriation of property by a staff member who cashed checks without consent. The staff member was arrested and removed from the facility, and corrective actions were initiated.
Deficiencies (1)
F602: The facility failed to protect a resident from misappropriation of property when a staff member cashed checks without the resident's consent. The staff member admitted to forging the resident's signature and was arrested and terminated.
Report Facts
Resident census: 137
Amount misappropriated: 4400
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Activities Director | Staff member who cashed checks and was arrested for misappropriation | |
| Business Office Manager | Notified about suspicious activity on resident's account | |
| Administrator | Began investigation after notification of misappropriation |
Inspection Report
Plan of Correction
Census: 131
Deficiencies: 1
Date: May 18, 2022
Visit Reason
The visit was conducted to investigate and document a deficiency related to misappropriation and exploitation of a resident's property by a staff member.
Findings
The facility failed to ensure one resident was free from misappropriation of property when a staff member used the resident's bank card for personal use. The facility took disciplinary action, notified authorities, and corrected the non-compliance.
Deficiencies (1)
F602: The facility failed to protect a resident from misappropriation of property when a staff member used the resident's bank card for personal use. The resident's bank statement showed multiple unauthorized Cash App transactions totaling over $1300.
Report Facts
Facility census: 131
Unauthorized Cash App transaction total: 1300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in misappropriation finding and termination |
| Director of Nurses | Director of Nursing | Interviewed regarding notification and investigation |
Inspection Report
Annual Inspection
Census: 131
Deficiencies: 6
Date: May 6, 2022
Visit Reason
Annual inspection survey conducted from 5/3/2022 to 5/6/2022 to assess compliance with federal and state regulations at St Joe Manor nursing facility.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment with multiple ceiling tile and vent issues. The facility failed to accurately code Minimum Data Set (MDS) assessments for several residents and did not develop individualized comprehensive care plans for some residents. Additional deficiencies included failure to properly assess and monitor bed rails, side rails, and handrails, and lack of policies for maintenance and protective oversight.
Deficiencies (6)
F584 Safe Environment. The facility failed to maintain a safe, clean, comfortable, and homelike environment as evidenced by multiple stained, broken, or missing ceiling tiles and vents throughout the building.
F641 Accuracy of Assessments. The facility failed to accurately code the Minimum Data Set (MDS) for six residents, including incorrect pneumonia diagnoses and catheter use documentation.
F656 Develop/Implement Comprehensive Care Plan. The facility failed to develop and implement individualized comprehensive care plans with measurable objectives for two residents.
F657 Care Plan Timing and Revision. The facility failed to update and revise care plans timely for two residents based on assessments and condition changes.
F700 Bedrails. The facility failed to appropriately assess, monitor, and document the use of bed rails and side rails for two residents, including lack of proper assessments and interventions.
F924 Corridors have Firmly Secured Handrails. The facility failed to ensure handrails in corridors were firmly attached, with loose handrails observed near rooms 203, 213, 512, and 513.
Report Facts
Facility census: 131
Residents sampled: 26
Residents with MDS coding errors: 6
Residents with care plan deficiencies: 2
Residents with bed rail issues: 2
Inspection Report
Life Safety
Census: 131
Deficiencies: 8
Date: May 6, 2022
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain adequate exit signage, maintain high hazard areas free of damages, keep kitchen facilities properly functioning, maintain fire extinguishers, enforce smoking regulations, prohibit portable space heaters, maintain the emergency generator, and prohibit temporary wiring. These deficiencies potentially affected all residents and staff.
Deficiencies (8)
K293 Exit Signage: The facility failed to maintain adequate exit signage with directional indicators and continuous illumination, potentially affecting all residents and staff.
K321 Hazardous Areas - Enclosure: The facility failed to maintain high hazard areas free of damages, reducing smoke rating and fire protection, potentially affecting all residents and staff.
K324 Cooking Facilities: The facility failed to maintain kitchen hood filters properly, with heavy grease buildup observed, potentially affecting all residents and staff.
K355 Portable Fire Extinguishers: The facility failed to maintain fire extinguishers properly, including improper mounting height and inspection dates, potentially affecting all residents and staff.
K741 Smoking Regulations: The facility failed to maintain smoking areas properly, with cigarette butts, damaged containers, and flammable furniture observed, potentially affecting all residents and staff.
K781 Portable Space Heaters: The facility failed to prohibit portable space heaters, with a space heater observed in the therapy department, potentially affecting all residents and staff.
K918 Electrical Systems - Essential Electric System: The facility failed to maintain the emergency generator properly, lacking sufficient fuel supply and maintenance, potentially affecting all residents and staff.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to prohibit use of temporary wiring and extension cords, with cords observed in use, potentially affecting all residents and staff.
Report Facts
Facility Census: 131
Inspection Report
Annual Inspection
Census: 131
Deficiencies: 6
Date: May 6, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to maintaining a safe, clean, and homelike environment, accurate resident assessments, care planning, use of restraints and side rails, and physical safety features such as handrails.
Findings
The facility was found deficient in maintaining a safe and clean environment with multiple ceiling tile issues and stains, failed to accurately code Minimum Data Set (MDS) assessments for several residents, did not develop or update individualized comprehensive care plans with specific interventions for residents, failed to properly assess and monitor the use of bed rails and side rails, and did not ensure handrails in hallways were securely attached.
Deficiencies (6)
Facility failed to maintain a safe, clean, comfortable, and homelike environment with multiple stained, broken, or missing ceiling tiles and vents.
Facility failed to accurately code the Minimum Data Set (MDS) assessments for six residents.
Facility failed to develop and implement individualized comprehensive care plans with specific interventions for two residents.
Facility failed to update and revise care plans with specific interventions tailored to meet the needs of two residents.
Facility failed to appropriately assess the use of bed rails/side rails for two residents, including lack of documentation of alternative methods, monitoring, and assessments.
Facility failed to ensure handrails on the 200 and 500 halls were properly attached to the wall.
Report Facts
Residents sampled: 26
Facility census: 131
Deficiencies cited: 6
Dates of maintenance requests: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Interviewed regarding maintenance reporting and broken equipment | |
| Housekeeping staff E | Interviewed regarding reporting broken equipment and housekeeping issues | |
| Certified Nurse Aide (CNA) D | Interviewed regarding reporting broken equipment | |
| Licensed Practical Nurse (LPN) F | Interviewed regarding maintenance concerns and paging maintenance staff | |
| Maintenance Director | Interviewed regarding responsibility for facility maintenance and requisition process | |
| Administrator | Interviewed regarding maintenance requisitions and roof replacement | |
| MDS Coordinator | Interviewed regarding accuracy and responsibility for Minimum Data Set assessments and care plans | |
| Director of Nursing (DON) | Interviewed regarding resident assessments, care plans, and side rail assessments | |
| Certified Nursing Assistant (CNA) C | Interviewed regarding resident bed/chair alarm use | |
| Licensed Practical Nurse (LPN) B | Interviewed regarding bed/chair alarm checks |
Inspection Report
Complaint Investigation
Census: 130
Deficiencies: 2
Date: Jan 18, 2022
Visit Reason
The inspection was conducted in response to complaints #MO195731 and #MO196002 regarding inadequate provision of showers and bathing assistance to residents.
Complaint Details
Complaint #MO195731 and #MO196002 were investigated. The complaints were substantiated based on findings of inadequate showering and bathing assistance.
Findings
The facility failed to ensure residents who require assistance with activities of daily living received adequate grooming and bathing services. Multiple residents reported and documented receiving fewer showers than scheduled due to insufficient staff.
Deficiencies (2)
F658 Services Provided Meet Professional Standards. The facility failed to ensure residents unable to carry out activities of daily living received necessary grooming and bathing services, as evidenced by multiple residents receiving fewer showers than scheduled due to lack of staff.
A4076 Clean, Dry, Odor Free. The facility failed to ensure each resident was clean, dry, and free of offensive body and mouth odor, as referenced in complaint #MO195731 and #MO196002.
Report Facts
Facility census: 130
Shower opportunities received: 1
Shower opportunities received: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S. Greco | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Plan of Correction
Census: 7
Deficiencies: 2
Date: Oct 18, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction following a survey completed on 10/18/2021 at St Joe Manor.
Findings
The facility failed to ensure residents and/or their legally authorized representatives were fully informed of their rights and responsibilities upon admission and annually. The facility also failed to complete or conduct updated advance directives documentation for one resident out of three reviewed.
Deficiencies (2)
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: The facility failed to ensure residents or their legally authorized representatives were fully informed of rights and responsibilities annually for three residents. The facility census was 7.
19 CSR 30-88.010(10) Advance Directive Requirements: The facility failed to complete or conduct updated advance directive documentation for one resident out of three reviewed. The facility census was 7.
Report Facts
Facility census: 7
Residents reviewed: 3
Inspection Report
Routine
Deficiencies: 0
Date: Sep 14, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted on September 14, 2021.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 18, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and complaint inspection were conducted on 08/18/21 to assess compliance with relevant regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control. No deficiencies were cited during this onsite visit.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with related regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint investigation on 10/22/20.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 11
Date: Sep 27, 2019
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment at the facility.
Complaint Details
The investigation was triggered by allegations of verbal abuse by a Certified Nursing Assistant (CNA) toward a resident. The allegation was substantiated and the CNA's employment was terminated.
Findings
The facility failed to immediately notify the administrator of alleged verbal abuse by a staff member, failed to notify the Office of the State Long-Term Care Ombudsman of a resident transfer, failed to complete a comprehensive resident assessment within required timeframes, failed to ensure staff were properly trained and certified in CPR, and had multiple other deficiencies related to nursing staff coverage, medication management, infection control, and resident care.
Deficiencies (11)
F609: The facility failed to immediately notify the administrator of alleged verbal abuse by a staff member to a resident. The administrator substantiated the allegation and terminated the staff member's employment.
F623: The facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident transfer to the hospital. No documentation of notification was found in the resident's medical record.
F636: The facility failed to complete a comprehensive resident assessment within 366 days for one resident. The facility also lacked a policy on completing comprehensive assessments.
F678: The facility failed to ensure staff were properly trained and certified in cardiopulmonary resuscitation (CPR). Several staff had CPR certification obtained online only, which is not acceptable.
F698: The facility failed to obtain a physician's order for dialysis and failed to provide documentation of ongoing communication with the dialysis center for one resident receiving dialysis.
F727: The facility failed to provide the services of a registered nurse for eight consecutive hours per day, seven days a week, as required.
F758: The facility failed to provide an appropriate diagnosis for use of antipsychotic medications for two residents and failed to follow regulations regarding psychotropic drug use and PRN orders.
F803: The facility failed to follow and prepare food according to the recipe book, affecting three residents on pureed diets.
F880: The facility failed to establish and maintain an infection prevention and control program, including annual review and antibiotic stewardship.
F881: The facility failed to establish and maintain an antibiotic stewardship program to monitor antibiotic use among residents.
F883: The facility failed to provide pneumococcal and influenza immunization education and documentation to residents and their representatives as required.
Report Facts
Facility census: 75
Deficiencies cited: 11
Inspection Report
Life Safety
Census: 75
Deficiencies: 6
Date: Sep 27, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain several fire safety requirements including exit egress doors free from impediments, kitchen range hood maintenance, fire alarm system functionality, cautionary placards near fire extinguishers, exit corridor door operation, and proper oxygen cylinder storage. These deficiencies affected all residents, staff, and occupants in the event of a fire emergency.
Deficiencies (6)
K211 Means of Egress - General: The facility failed to maintain an exit egress door free from impediments, as panic hardware was painted over to look like a book shelf, preventing door opening during emergency.
K324 Cooking Facilities: The facility failed to maintain the kitchen range hood to NFPA standards; the range hood was not turned on while cooking, exposing residents and staff to fire hazards.
K345 Fire Alarm System - Testing and Maintenance: The fire alarm system did not sound or alert during testing, and the primary fire panel did not communicate with the alarm panel on the court side.
K355 Portable Fire Extinguishers: The facility failed to maintain a cautionary placard near the K-class fire extinguisher in the kitchen as required by NFPA 10 standards.
K361 Corridors - Areas Open to Corridor: The facility failed to maintain exit corridor doors free from impediments; a dutch door was partially removed preventing proper closure.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain oxygen cylinders properly; mixed full and empty tanks were not segregated and lacked proper signage.
Report Facts
Facility census: 75
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 5
Date: Apr 24, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of abuse and neglect, including a resident sustaining head trauma and subsequent death.
Complaint Details
Complaint #MO155273 involved allegations of abuse and neglect resulting in Resident #1 sustaining severe head trauma and subsequent death. The complaint was substantiated with findings of immediate jeopardy and multiple class II violations.
Findings
The facility failed to ensure residents were free from abuse and neglect, including verbal, physical, and sexual abuse. The facility also failed to notify law enforcement of a reasonable suspicion of assault and did not implement adequate protective interventions for residents at risk.
Deficiencies (5)
F600 Freedom from Abuse and Neglect: The facility failed to prevent verbal, mental, sexual, or physical abuse, resulting in Resident #1 suffering head trauma and death after an altercation with Resident #2.
F608 Reporting of Reasonable Suspicion of a Crime: The facility failed to notify law enforcement of a reasonable suspicion of assault on Resident #1 by Resident #2.
F609 Reporting of Alleged Violations: The facility failed to immediately report allegations of abuse, neglect, exploitation, or mistreatment to appropriate authorities.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement comprehensive, person-centered care plans for residents exhibiting behavioral problems and at risk for wandering.
F744 Treatment/Service for Dementia: The facility failed to thoroughly investigate allegations of resident-to-resident altercations to rule out abuse.
Report Facts
Facility census: 77
Deficiencies cited: 5
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Date: Apr 3, 2019
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to notify a physician about a significant decline in condition of a resident.
Complaint Details
Complaint #MO154434 was investigated and found no state licensure deficiencies as a result of this complaint only investigation.
Findings
The facility failed to contact the physician for a significant decline in condition of one resident. The facility lacked a policy on when to notify the physician regarding a decline in health status.
Deficiencies (1)
F580 Notification of Changes. The facility failed to notify the physician of a significant decline in condition of a resident and lacked a policy on when to contact the physician regarding resident decline.
Report Facts
Resident census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in finding related to failure to notify physician |
| LPN B | Licensed Practical Nurse | Named in finding related to notifying physician and resident transfer |
| Director of Nurses | Director of Nursing (DON) | Interviewed regarding notification of physician |
| Administrator | Administrator (ADM) | Interviewed regarding facility policy on physician notification |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 11
Date: Nov 30, 2018
Visit Reason
Annual inspection of St Joe Manor nursing facility to assess compliance with federal and state regulations including resident transfer/discharge notices, resident assessments, infection control, and care planning.
Findings
The facility was found noncompliant in multiple areas including failure to provide timely and proper transfer/discharge notices, incomplete comprehensive and quarterly resident assessments, inadequate bed hold policies, deficient infection control practices, insufficient staff training, and incomplete documentation of care plans and immunizations.
Deficiencies (11)
F623 Notice Requirements Before Transfer/Discharge: Facility failed to notify residents or their representatives in writing of transfers or discharges and did not provide required transfer notices.
F625 Notice of Bed Hold Policy: Facility failed to inform residents and families in writing of the bed hold policy at the time of hospital transfer or therapeutic leave.
F636 Comprehensive Assessments & Timing: Facility failed to complete comprehensive Minimum Data Set assessments within required timeframes for multiple residents.
F637 Comprehensive Assessment After Significant Change: Facility failed to complete significant change assessments within 14 days for hospice residents.
F638 Quarterly Review Assessment: Facility failed to complete quarterly resident assessments at least every 92 days for multiple residents.
F655 Baseline Care Plan: Facility failed to develop and provide residents and representatives with baseline care plans within 48 hours of admission.
F658 Services Provided Meet Professional Standards: Facility failed to follow physician orders and notify physicians regarding abnormal blood sugar readings for residents.
F730 Nurse Aide Performance Review: Facility failed to ensure certified nurse aides received required annual 12-hour training and did not document training hours properly.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility failed to maintain sanitary kitchen conditions including burned baking sheets, grease buildup, and improper handwashing sink temperature.
F880 Infection Prevention & Control: Facility failed to maintain infection control practices including cleaning and disinfecting glucometers and maintaining an effective infection prevention program.
F883 Influenza and Pneumococcal Immunizations: Facility failed to provide education, obtain signed consent/refusal forms, and document immunizations for residents.
Report Facts
Facility census: 81
Certified Nurse Aides: 5
Training hours: 12
Training sessions: 2
Audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amber Dunn | MDS Coordinator | Interviewed regarding MDS completion and assessments. |
| Director of Nursing | Director of Nursing | Interviewed regarding blood sugar monitoring protocols and staff training. |
| Staff Coordinator | Staff Coordinator | Interviewed regarding CNA in-service training documentation. |
| Certified Medication Technician C | Certified Medication Technician | Interviewed regarding blood sugar monitoring and glucometer cleaning. |
| Registered Nurse B | Registered Nurse | Interviewed regarding blood sugar monitoring procedures. |
| Licensed Practical Nurse L | Licensed Practical Nurse | Interviewed regarding physician notification for blood sugar readings. |
Inspection Report
Life Safety
Census: 81
Deficiencies: 6
Date: Nov 30, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related reference documents.
Findings
The facility failed to maintain doors free of obstructions, adequate exit signage, proper storage of alcohol-based hand rub dispensers, maintenance of sprinkler heads, smoking ash cans, and proper use of power strips. These deficiencies potentially affected all residents and staff.
Deficiencies (6)
K222 Egress Doors: The facility failed to maintain doors free of obstructions, including a laundry room door propped open with a bucket and a serving door with a kick down door stop in use during the survey.
K293 Exit Signage: The facility failed to maintain adequate exit signage and illumination, including no exit signage from the service hall area of the kitchen and no illumination or exit lights in the exit route from the kitchen.
K325 Alcohol Based Hand Rub Dispenser: The facility failed to maintain safe storage of alcohol hand sanitizers, with 49 liters stored in the housekeeping storage exceeding allowed limits.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler heads, with seven heads in the kitchen heavily corroded and one with caulking on the bulb.
K741 Smoking Regulations: The facility failed to maintain smoking ash cans free of combustibles, with ash cans full of used cigarettes and burnt materials.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to prohibit power strips in use, including piggy-backed power strips in the office adjacent to the ADON office.
Report Facts
Facility census: 81
Alcohol hand sanitizer volume: 49
Sprinkler heads corroded: 7
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 3
Date: Jan 11, 2018
Visit Reason
The inspection was conducted as a complaint investigation related to failure to notify physician of changes in resident condition and failure to follow professional standards of care.
Complaint Details
The complaint investigation was substantiated as the facility failed to notify the physician of Resident #1's deteriorating condition and failed to meet professional standards of care.
Findings
The facility failed to notify the physician about the deterioration of a resident's condition related to a wrist cast and failed to follow physician orders and professional standards of care. The resident suffered from a severely poor condition of the cast, an open wound with drainage, and delayed medical clearance for surgery.
Deficiencies (3)
F580 Notification of Changes: The facility failed to promptly notify the physician when Resident #1's wrist cast condition deteriorated, resulting in injury and delayed treatment.
F658 Services Provided Meet Professional Standards: The facility failed to follow physician orders and professional standards for Resident #1's care, including monitoring and documenting the cast condition and arranging timely medical appointments.
F684 Quality of Care: The facility failed to accurately assess and document Resident #1's cast condition, resulting in an open wound with exposed bone and delayed surgery clearance.
Report Facts
Facility census: 75
Days delayed for surgery clearance: 22
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