Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Joe Manor during CMS and state inspections, most recent first.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers, as required by policy. This deficiency affected multiple residents, with no documentation of written notifications at the time of transfer. Interviews with staff revealed that the responsibility for sending transfer forms lies with floor nurses, but the expected notifications were not documented.
The facility failed to provide written information about the bed hold policy to residents and/or their representatives at the time of hospital transfer. This deficiency was noted for four residents, despite the facility's policy requiring such information to be given in writing. Interviews indicated that floor nurses were responsible for this task, but documentation was lacking.
The facility failed to accurately document MDS assessments for four residents, leading to discrepancies in recorded medical information. A resident's MDS inaccurately recorded insulin injections, while another's did not reflect hospice status. The facility lacked a policy on MDS accuracy, contributing to these errors, despite expectations from the MDS Coordinator and administration for accurate assessments.
The facility failed to implement comprehensive care plans for four residents, resulting in deficiencies in addressing their individual needs. A resident with paraplegia used side rails not included in their care plan. Another resident with sleep apnea used oxygen and a BIPAP machine, which were not documented. A third resident with COPD used oxygen therapy not reflected in their care plan. Lastly, a resident with chronic UTIs was on antibiotics, but their care plan did not address UTI management. The facility's policy requires care plans to be updated, but this was not followed.
The facility failed to update and revise care plans for several residents, leading to deficiencies in addressing individual needs. A resident's care plan did not address vape use, another was inaccurately listed as full code despite hospice care, and a third was not informed about care plan meetings. Additionally, a resident with multiple falls had outdated fall risk interventions, and another's care plan lacked bleeding precautions for an anticoagulant. The administration acknowledged the expectation for care plans to reflect current conditions.
Two residents in the facility did not receive consistent showers as per their scheduled ADLs, leading to extended periods without proper hygiene. One resident, with multiple health conditions, reported receiving showers only once every two weeks, while another resident with Parkinson's disease reported having only one shower a month. Staff interviews confirmed that residents should receive two showers per week, but records showed multiple missed opportunities.
A facility failed to obtain a physician's order for oxygen administration and did not ensure a BIPAP order included settings for a resident with multiple respiratory and cardiac conditions. The resident was observed using oxygen and a BIPAP machine without documented orders, and staff interviews confirmed the lack of necessary orders.
The facility failed to maintain a medication error rate below five percent, resulting in an 8.57% error rate due to improper insulin administration. Three residents were affected as insulin pens were not primed before use, contrary to manufacturer instructions. CMTs misunderstood the priming process, believing it was only necessary when the pen was first used. The ADON and DON confirmed the expectation to follow manufacturer's guidelines.
A facility failed to maintain proper infection control practices during foley catheter care for a resident. A CNA did not adhere to the facility's Handwashing/Hand Hygiene Policy and EBP policy, failing to perform hand hygiene between tasks and not wearing a gown as required. The CNA admitted to not knowing the location of gowns and acknowledged the need for hand hygiene. The facility's administration confirmed the expectation for staff to adhere to proper PPE use and hand hygiene protocols.
A facility failed to follow infection control practices during perineal care for a resident with a PICC line. Staff did not adhere to the Enhanced Barrier Precaution (EBP) policy, which required wearing gowns, gloves, and masks. Observations showed that CNAs did not wash hands before donning gloves or after removing them, and did not clean the area before placing a brief. Interviews revealed a lack of understanding of EBP requirements, and the administration acknowledged the failure to follow policy.
Facility staff failed to report a resident-to-resident abuse incident to the state licensing agency. A resident pushed another, causing a fall and head injury requiring staples. The DON did not report the incident, believing it unnecessary unless harm occurred, despite the facility's policy requiring such reports. The Administrator expected the incident to be reported, highlighting a protocol discrepancy.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives in writing of transfers or discharges to a hospital, including the reasons for such transfers, for eleven residents out of 28 sampled and one additional resident outside the sample. This deficiency was identified through interviews and record reviews, revealing a lack of documentation that the residents' representatives were informed in writing at the time of transfer. The facility's policy, revised in October 2022, mandates written notification to residents and their representatives, including specific details about the transfer or discharge, the effective date, and the new location. The policy also requires that a copy of the notice be sent to the Office of the State Long-Term Care Ombudsman. However, the review showed that for multiple residents, including those who were transferred to the hospital on various dates, there was no documentation of written notification to the residents' representatives. The facility's policy considers transfers to acute care settings as facility-initiated transfers, not discharges, and expects residents to return to the facility. Despite this, the required notifications were not documented. Interviews with facility staff, including the Social Services Designee and Registered Nurse, indicated that the responsibility for sending out transfer forms lies with the floor nurses. The Administrator, Director of Nursing, and Assistant Director of Nursing acknowledged the expectation that residents and their representatives should be notified in writing of transfers. The lack of documentation for these notifications constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
The facility failed to provide written information to residents and/or their representatives regarding the facility's bed hold policy at the time of transfer to the hospital. This deficiency was identified for four residents out of a sample of 28, despite the facility's policy requiring that such information be provided in writing at least twice: in advance of any transfer and at the time of transfer. The policy, revised in October 2022, mandates that residents and their representatives be informed of the bed hold policies, which address holding or reserving a resident's bed during periods of absence, such as hospitalization or therapeutic leave. Interviews with facility staff revealed that the responsibility for sending out the bed hold policies lies with the floor nurses at the time of resident discharge. However, there was no documentation in the medical records of the four residents indicating that they or their representatives were informed in writing of the bed hold policy at the time of their transfers to the hospital. The facility's administration, including the Administrator, Director of Nursing, and Assistant Director of Nursing, collectively acknowledged the expectation that residents and/or their representatives should be made aware of bed holds in writing.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to document accurate Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in the recorded medical information. Resident #40's medical record indicated that they received an injection of Ozempic but did not receive insulin during the seven-day look-back period. However, the MDS assessment inaccurately recorded that the resident received one insulin injection. Similarly, Resident #41's record showed an injection of Ozempic without any insulin received, yet the MDS assessment incorrectly noted one insulin injection. Resident #131's medical record documented two Haldol injections, but the MDS assessment marked zero injections received in the look-back period. Lastly, Resident #138, who was admitted to hospice, had an MDS assessment that inaccurately marked 'no' for a condition that may result in a life expectancy of less than six months. The facility did not provide a policy regarding MDS accuracy, which may have contributed to these inaccuracies. Interviews with the MDS Coordinator and the facility's administration, including the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), revealed an expectation for MDS assessments to accurately reflect the residents' conditions at the time of assessment. Despite this expectation, the discrepancies in the MDS documentation for these residents indicate a failure to meet this standard, as evidenced by the inaccurate coding of injections and hospice status.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plans with specific interventions for four residents, leading to deficiencies in meeting their individual needs. Resident #31, who has diagnoses including paraplegia and rheumatoid arthritis, was observed using side rails for mobility, yet their care plan did not address the use of side rails. This oversight indicates a lack of alignment between the resident's needs and the documented care plan. Resident #41, diagnosed with obstructive sleep apnea and other respiratory conditions, was observed using oxygen and a BIPAP machine, but their care plan did not include these critical interventions. Similarly, Resident #55, with COPD and atrial fibrillation, was using oxygen therapy, which was not reflected in their care plan. These omissions suggest a failure to update care plans to reflect the residents' current medical needs and prescribed treatments. Resident #111, who has a history of chronic UTIs and other health issues, was taking antibiotics for a UTI, yet their care plan did not address the management of chronic UTIs. The facility's policy requires care plans to be updated with measurable objectives and time frames, but these were not adhered to, as evidenced by the lack of updates in response to significant changes in the residents' conditions. The facility's administration acknowledged the expectation for care plans to be current and reflective of residents' conditions.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans with specific interventions to meet the individual needs of five residents. Resident #1's care plan did not address the use of vapes, despite observations of the resident having a vape in their room and on their lap. Additionally, the resident reported not taking any medications, yet the care plan included several medication-related interventions. Resident #6's care plan inaccurately listed the resident as a full code, despite an order for hospice care and a DNR status. Resident #18 was not informed about upcoming care plan meetings, and there was no documentation to indicate that the resident was notified, despite expressing a desire to attend these meetings. Resident #34 experienced twelve unwitnessed falls, including falls with injuries, but the care plan's fall risk interventions had not been updated since August 2023. This lack of updated interventions occurred despite a significant change in the resident's condition, as indicated by a recent MDS assessment. Resident #126's care plan failed to address bleeding precautions and interactions related to the prescribed anticoagulant, Apixaban. Additionally, the care plan did not address the resident's use of marijuana, despite noting the resident's unsupervised smoking and vaping habits. The facility's administration acknowledged the expectation for care plans to reflect the current condition of residents, which was not met in these cases.
Inconsistent Shower Schedule for Residents
Penalty
Summary
The facility failed to provide consistent care for activities of daily living (ADLs) for two residents, resulting in extended periods without showers. Resident #24, who has multiple health conditions including arthritis, spinal stenosis, COPD, diabetes, heart failure, morbid obesity, and severe chronic kidney disease, reported receiving showers only once every two weeks despite being scheduled for twice a week. The resident expressed feeling dirty and uncomfortable with facial hair due to the infrequent showers. Records showed that in December 2024, the resident missed six out of nine scheduled showers, and in January 2025, missed another six out of nine. Similarly, Resident #55, diagnosed with Parkinson's disease, COPD, heart failure, and other conditions, reported having only one shower a month, despite being scheduled for two per week. The resident expressed concern about personal hygiene and odor. Records indicated that in December 2024, the resident missed seven out of nine scheduled showers, and in January 2025, missed eight out of nine. Interviews with staff, including a CNA, RN, ADON, and DON, confirmed that residents should receive two showers per week, but the facility failed to adhere to this schedule consistently.
Failure to Obtain Orders for Oxygen and BIPAP Settings
Penalty
Summary
The facility failed to obtain a physician's order for oxygen administration and did not ensure that a physician's order for bilevel positive airway pressure (BIPAP) included the necessary settings for a resident. This deficiency affected one resident who had multiple diagnoses, including obstructive sleep apnea, shortness of breath, respiratory failure, chronic kidney disease, heart failure, and chronic obstructive pulmonary disease. The resident was observed using oxygen via nasal cannula at 3.5 liters per minute and had a BIPAP machine at bedside, but there were no documented orders for the oxygen or the BIPAP settings. Interviews with the resident and facility staff, including a Licensed Practical Nurse (LPN), a Registered Nurse (RN), the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, confirmed the lack of necessary orders. The resident reported regular use of oxygen and BIPAP at bedtime, while the staff acknowledged that orders for oxygen and BIPAP settings should be in place. The facility's policy required a review of the physician's order for BIPAP settings, but this was not followed, leading to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration, resulting in an error rate of 8.57%. This deficiency affected three residents out of seven sampled. The errors were related to the improper administration of insulin using pen-type devices, specifically the failure to prime the insulin pens before administration, as required by the manufacturer's instructions. This oversight was observed in the administration of both NovoLog and Insulin Lispro to the residents. Resident #32 received three units of NovoLog without the pen being primed, despite a blood sugar level of 204. Similarly, Resident #102 was administered six units of Insulin Lispro without priming the pen for a blood sugar level of 236. Resident #133 also received three units of Insulin Lispro without the pen being primed. Interviews with the Certified Medication Technicians (CMTs) involved revealed a misunderstanding of the priming process, as they believed priming was only necessary when the pen was first used. The Assistant Director of Nursing and the Director of Nursing confirmed that staff are expected to follow the manufacturer's guidelines for insulin administration.
Infection Control Deficiency in Foley Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices and implement Enhanced Barrier Protections (EBP) during foley catheter care for a resident. The facility's Handwashing/Hand Hygiene Policy and EBP policy were not adhered to by a Certified Nursing Aide (CNA) during the care of a resident with a foley catheter. The CNA did not wash or sanitize hands before donning gloves, did not wear a gown as required by EBP, and failed to perform hand hygiene between dirty and clean tasks and before leaving the resident's room. During the observation, the CNA was seen entering the resident's room, donning gloves without prior hand hygiene, and not wearing a gown despite EBP signage and supplies being accessible. The CNA performed catheter care and peri care without proper hand hygiene between tasks and left the room with trash without sanitizing hands. The CNA admitted to not knowing the location of gowns and acknowledged the need for hand hygiene between tasks and before leaving the room. The facility's administration confirmed the expectation for staff to adhere to proper PPE use and hand hygiene protocols.
Infection Control Deficiency During Perineal Care
Penalty
Summary
The facility failed to maintain proper infection control practices during perineal care for a resident with a Peripherally Inserted Central Catheter (PICC). The facility's Perineal Care Policy and Enhanced Barrier Precaution (EBP) Policy were not followed. During an observation, it was noted that a Certified Nursing Aide (CNA) donned gloves without washing hands and performed perineal care without cleaning the area first. Additionally, the CNA did not wash hands after removing gloves and before leaving the room. The EBP signage on the resident's door indicated the need for protective gear, but the staff did not adhere to these guidelines. Interviews with the staff revealed a lack of understanding and adherence to the EBP policy. CNA A and CNA B did not wear the required gown, gloves, and mask during care for the resident with a PICC line, despite the policy indicating that EBP should be used for residents with such devices. The Licensed Practical Nurse (LPN) confirmed that EBP should be worn for residents with medical devices like a PICC line. The resident also reported that staff had not been wearing gowns during care, only masks and gloves during PICC line care. The facility's administration acknowledged that the staff should have followed the policy and washed hands between dirty and clean tasks.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility staff failed to report an incident of resident-to-resident abuse to the state licensing agency as required. The incident involved two residents, where one resident pushed another, resulting in a fall that caused a head injury requiring two staples and a skin tear on the elbow. The facility's policy mandates reporting such incidents to the state agency, but this was not done. The Director of Nursing (DON) was informed by the state licensing agency that reporting was not necessary unless harm occurred, which led to the decision not to report the incident. The incident occurred when one resident accused another of stealing food and pushed them, causing the fall. The facility's investigation noted the fall was unwitnessed and did not initially observe injuries on the resident who fell. However, the resident was later transferred to the hospital due to the injuries sustained. The Administrator expressed that such incidents should be reported to the state licensing agency, indicating a discrepancy between the facility's actions and the expected protocol.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bonne Terre
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Desloge | 4 mi | — | 0 | 0 |
| Country Meadows | 4.7 mi | — | 1 | 0 |
| Community Manor | 10.6 mi | — | 1 | 0 |
| Camelot Nursing And Rehabilitation Center | 10.9 mi | — | 7 | 0 |
| Southbrook Nursing Center | 11.1 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.