Inspection Reports for
St Joseph Residence Inc
495 Mammoth Rd, Manchester, NH 03104, NH, 03104
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Census: 22
Deficiencies: 3
Date: Dec 23, 2025
Visit Reason
The inspection was conducted to assess compliance with staffing requirements, accuracy of Payroll Based Journal (PBJ) staffing data submissions, and implementation of the facility's infection prevention and control program including the water management plan.
Findings
The facility failed to ensure licensed nurse coverage 24/7 for 8 of 12 days reviewed, failed to submit accurate PBJ staffing data for 7 of 92 days reviewed, and failed to implement and review the water management plan annually, with inadequate documentation of flushing and cleaning procedures.
Deficiencies (3)
Failed to ensure that a Licensed Nurse was on duty 24 hours a day, 7 days a week, for 8 of 12 days reviewed for Fiscal Year Quarter 4 (July 1, 2025 - September 30, 2025).
Failed to submit accurate Payroll Based Journal (PBJ) staffing data for 7 of 92 days reviewed for Fiscal Quarter 4 (July 1, 2025 - September 30, 2025).
Failed to implement and review, at least annually, the facility's water management plan that has the potential to affect the facility census of 22 residents, including lack of documentation for shower head cleaning and insufficient flushing documentation.
Report Facts
Days without licensed nurse coverage: 8
Days with inaccurate PBJ data submission: 7
Facility census: 22
Dates of missing licensed nurse coverage: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Resource Manager | Interviewed and confirmed findings related to licensed nurse coverage and PBJ data inaccuracies | |
| Infection Preventionist | Interviewed regarding water management plan and infection control deficiencies | |
| Maintenance Assistant | Interviewed regarding water management plan and infection control deficiencies |
Inspection Report
Routine
Deficiencies: 4
Date: Oct 31, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration, nutritional interventions, staffing data submission, and immunization policies at St Joseph Residence.
Findings
The facility failed to follow physician's orders for medication administration for one resident, failed to provide ordered nutritional supplements for another resident, failed to submit complete and accurate staffing data for five days in a fiscal quarter, and failed to ensure a resident was offered and/or provided the pneumococcal vaccine as ordered.
Deficiencies (4)
Failed to follow physician's orders for medication administration for Resident #20.
Failed to follow physician's orders for nutritional intervention for Resident #19.
Failed to submit complete and accurate direct care staffing data for 5 of 91 days reviewed for Fiscal Quarter 3.
Failed to ensure Resident #18 was offered and/or provided the pneumococcal vaccine as ordered.
Report Facts
Deficiency count: 4
Days with missing licensed nursing coverage: 5
Resident #19 weight on 9/16/24: 104.9
Resident #19 weight on 10/21/24: 101
Resident #19 weight on 9/1/24: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Nursing Assistant | Named in medication administration error for Resident #20 |
| Staff C | Registered Dietician | Signed nutritional assessment for Resident #19 |
| Staff D | Licensed Nursing Assistant | Interviewed regarding nutritional supplement administration for Resident #19 |
| Staff E | Licensed Practical Nurse | Confirmed nutritional supplement was not given to Resident #19 |
| Staff F | Revealed order for Ensure was not on Medication Administration Record or meal ticket for Resident #19 | |
| Staff G | Cook | Interviewed about meal service for Resident #19 |
| Staff H | Human Resources | Confirmed missing hours reported for PBJ staffing data |
| Staff A | Infection Preventionist | Interviewed about pneumococcal vaccine administration for Resident #18 |
Inspection Report
Routine
Deficiencies: 4
Date: Nov 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident safety, food storage, staffing data accuracy, and staff training at St Joseph Residence nursing home.
Findings
The facility was found to have multiple deficiencies including unsafe storage of chemical cleaning solutions accessible to residents, improper food storage with expired items, inaccurate staffing data submissions for several days, and lack of training for agency staff on abuse prevention.
Deficiencies (4)
Failed to ensure residents' environment was free from accident hazards due to chemical cleaning solutions stored within reach of residents on multiple units.
Failed to store food in accordance with professional standards, including presence of expired raw eggs and spoiled pumpkin puree in kitchen refrigerators.
Failed to submit complete and accurate direct care staffing information for 6 of 92 days reviewed for Fiscal Quarter 3 (April 1, 2023 - June 30, 2023).
Failed to provide training and education on abuse, neglect, exploitation, and misappropriation of resident property to 2 of 5 staff reviewed (agency staff).
Report Facts
Deficiency days with inaccurate staffing data: 6
Raw eggs with expired manufacturer's best by date: 26
Unopened sour cream containers expired: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Interviewed regarding residents wandering and chemical storage. |
| Staff B | Director of Nursing | Confirmed chemical storage findings and lack of agency staff education. |
| Staff C | Regional Nurse | Interviewed about lack of policy for secure chemical storage. |
| Staff F | Scheduler/Licensed Medication Nursing Assistant | Interviewed regarding residents wandering. |
| Staff G | Senior Cook | Confirmed food storage deficiencies. |
| Staff H | Corporate Human Resources | Confirmed inaccurate staffing data submissions. |
| Staff I | Administrator | Revealed no audit of PBJ submissions for accuracy. |
| Staff E | Agency Licensed Nursing Assistant | Found to have no training on abuse, neglect, exploitation. |
| Staff J | Agency Licensed Practical Nurse | Found to have no training on abuse, neglect, exploitation. |
Inspection Report
Deficiencies: 0
Date: Mar 22, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for St Joseph Residence, indicating the results of a regulatory survey completed on 2023-03-22.
Findings
No health deficiencies were found during the inspection.
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