Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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. Joseph's Rehabilitation And Care Center during CMS and state inspections, most recent first.
The facility failed to report an unexpected, untoward death of a resident to the State Agency within required timeframes, as mandated by its abuse prevention policy and state licensure rules. The resident had multiple serious conditions, including end-stage kidney disease requiring hemodialysis, chronic respiratory failure, heart failure, diabetes, and COPD, with moderately impaired cognition and a care plan addressing dialysis needs and fistula monitoring. Nursing notes documented the resident was found nonresponsive in bed with no pulse or respirations, blood around the body and on the floor, a small open area at the bottom of the left arm fistula, and blood on the fingertips of the right hand, with no trauma or sharp objects present. The DON acknowledged the death was unanticipated and that, although an internal investigation was completed, the facility did not submit the incident or investigation results to the State Agency as required.
A dietary staff member failed to change gloves and wash hands after handling food, leading to potential cross-contamination. The staff member touched various kitchen items without following proper hygiene protocols, as confirmed by the Dietary Manager.
The facility failed to implement and revise fall prevention measures for three residents with cognitive impairments and high fall risks. One resident lacked required grip strips in their room, another experienced multiple falls without new interventions, and a third had no additional fall measures despite confusion and a fall incident. The DON confirmed these deficiencies.
The facility failed to adhere to hand hygiene protocols and proper use of PPE during care for residents on Enhanced Barrier Precautions, as observed in the care of several residents. Staff did not perform hand hygiene before and after glove use, and gowns were not worn during high-contact care activities. Additionally, the facility did not implement measures to prevent the growth of Legionella in the water system, as confirmed by the Administrator and Maintenance Supervisor.
The facility failed to offer and educate three residents on pneumococcal and influenza vaccines, as required by its policy. The residents' medical records lacked evidence of screening for vaccination status, education on risks and benefits, or offering the vaccines. The DON confirmed the absence of a process and responsible staff for screening immunization status at admission.
The facility failed to offer the COVID-19 vaccine and provide education about its risks and benefits to three residents. The facility's policy required screening and education at admission, but records showed no evidence of these actions. The DON confirmed the absence of a process for screening immunization status and lack of staff responsibility for this task.
The facility failed to notify the PCP about significant lapses in medication and treatment for two residents. One resident did not receive Memantine and CPAP treatment as ordered, and was not assisted with walking as prescribed. Another resident did not receive Prednisone, leading to hospitalization. The DON confirmed the PCP was not informed of these issues.
Two residents in an LTC facility did not receive prescribed medications and treatments due to unavailability and staff oversight. One resident missed Memantine doses and CPAP use, while another did not receive Prednisone, leading to hospitalization. The DON confirmed these deficiencies.
The facility failed to document the duration of antibiotic use for two residents, despite its Antibiotic Stewardship Program requiring such documentation. Both residents, with moderate cognitive impairment and various diagnoses, received continuous antibiotic therapy without specified stop dates. Interviews confirmed that staff had attempted to educate providers on the need for stop dates, but the antibiotics were continued without them.
Failure to Report Unexpected Resident Death to State Agency
Penalty
Summary
The facility failed to report an unexpected resident death, considered an adverse event, to the State Agency within required timeframes as outlined in its own abuse prevention policy and state licensure requirements. The facility’s Abuse: Prevention of and Prohibition Against Policy dated 4/25 stated that all allegations of potential abuse, neglect, exploitation, misappropriation, and adverse events were to be reported immediately to the administrator, with notification to law enforcement in the event of a potential crime, and to Adult Protective Services within 2 to 24 hours depending on the case. The policy further required that a written report be submitted to the State Agency within 5 business days of the allegation. Despite these requirements, review of the facility’s 2026 Facility Reported Incidents showed no evidence that the unexpected death of a resident was reported to the State Agency. The resident involved had multiple serious medical conditions, including metabolic encephalopathy, end-stage kidney disease, chronic respiratory failure, anemia, heart failure, diabetes, and COPD, and required hemodialysis. The resident’s cognition was moderately impaired, and the resident did not have a condition or chronic disease documented as likely to result in a life expectancy of less than six months. The care plan noted the need for hemodialysis, occasional refusals of dialysis and medications, and interventions such as daily assessment of the left arm fistula for bruit and thrill, encouragement to attend dialysis, and monitoring for signs of infection. Nursing progress notes documented that the resident was found nonresponsive in bed with no pulse or respirations, with blood around the body and on the floor, a small open area at the bottom of the left arm fistula, and blood on the fingertips of the right hand, with no signs of trauma or sharp objects nearby. During interview, the DON confirmed the death was unanticipated and untoward and that an internal investigation was completed to ensure no neglect was involved, but acknowledged the facility did not report the unexpected death or submit the investigation results to the State Agency within the required timeframe.
Improper Hand Hygiene and Glove Use During Meal Service
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene and glove use during a meal service, leading to a potential for cross-contamination. During the noon meal service, a dietary staff member, identified as DC-P, was observed handling food with gloved hands. After placing a piece of pork loin on a dinner plate and cutting it into small pieces, DC-P did not change gloves or wash hands before touching various kitchen items, including resident cards, dishes, and serving utensils. This action was contrary to the Drug Administration Food Code, which mandates that food employees wash their hands and change gloves to prevent cross-contamination. An interview with the Dietary Manager confirmed that the staff should have removed gloves, washed hands, and donned a new pair of gloves before handling other kitchen items.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adequately review, revise, and implement care plan interventions to prevent falls for three residents, leading to deficiencies in fall management. Resident 16, who had moderate cognitive impairment and was a high fall risk, did not have grip strips present on the floor in front of their recliner as required by their care plan. Despite multiple observations over several days, the grip strips were consistently missing, which was confirmed by the Director of Nursing (DON). Resident 19, also with moderate cognitive impairment and a high fall risk, experienced multiple falls without any new immediate interventions being implemented. The resident's care plan included various fall prevention measures, but after falls on two separate occasions, no additional interventions were put in place to prevent future incidents. The DON confirmed the lack of new interventions following these falls. Resident 7, who had a diagnosis of anemia, non-Alzheimer dementia, seizure disorder, and depression, experienced a fall while sitting on a floor mat next to the bed. The resident was confused and unaware of their limitations. Although an SBAR was completed and a urinalysis was ordered, no other fall interventions were implemented. The DON confirmed the timeline of the urinalysis and culture results, but no treatment was ordered, and no further fall prevention measures were taken.
Infection Control and PPE Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols, as observed in the care of Residents 17, 11, and 7. For Resident 17, a nurse aide did not perform hand hygiene before and after glove use during multiple care activities, including assisting the resident with dressing and personal hygiene. Similarly, for Resident 11, a nurse aide did not wash hands or use hand sanitizer before and after glove changes while providing toileting and incontinence care. These actions were confirmed by interviews with the Director of Nursing and the staff involved, who acknowledged the lapses in following the facility's hand hygiene policy. The facility also failed to utilize appropriate Personal Protective Equipment (PPE) during the care of Residents 34 and 7, who were on Enhanced Barrier Precautions (EBP). For Resident 7, staff did not wear gowns during high-contact care activities, such as toileting and incontinence care, despite the resident having a stage 4 pressure ulcer and being on EBP. This was confirmed by interviews with the staff involved and the Director of Nursing, who acknowledged that gowns should have been worn. Similarly, for Resident 34, a nurse aide did not wear a gown while assisting with wound care and other high-contact activities, which was confirmed by the staff and the Infection Preventionist. Additionally, the facility failed to develop and implement measures to prevent the growth of potential waterborne illnesses, such as Legionella. The facility did not conduct a risk assessment to identify potential sources and areas of risk for Legionella growth in the water system. This was confirmed by the Administrator and the Maintenance Supervisor, who acknowledged that no measures had been implemented to prevent the growth of Legionella in the facility's water systems.
Failure to Offer and Educate on Vaccinations
Penalty
Summary
The facility failed to ensure that three of five sampled residents were offered the pneumococcal and influenza vaccines and were educated about the associated risks and benefits. The facility's policy, revised on October 24, emphasized the importance of vaccinations for the health and well-being of long-term care residents, with procedures in place for screening residents at admission and annually for influenza. However, the facility did not adhere to these procedures, as evidenced by the lack of documentation in the electronic medical records of Residents 31, 197, and 244. These records showed no evidence of screening for vaccination status, education on the risks and benefits, or offering and administering the vaccines. During an interview, the Director of Nursing confirmed that the facility lacked a process and responsible staff for screening residents' immunization status upon admission. This oversight resulted in Residents 31, 197, and 244 not receiving the necessary education or being offered the influenza and pneumococcal vaccines. The facility's failure to implement its immunization policy and procedures led to this deficiency, impacting the residents' access to essential vaccinations.
Failure to Offer COVID-19 Vaccine and Education
Penalty
Summary
The facility failed to provide evidence that three residents were offered the COVID-19 vaccine or educated about its risks and benefits. The facility's policy required residents to be screened at admission to determine their vaccination status and eligibility, and to receive education about the vaccine before it was offered. However, the records for Residents 31, 197, and 244 showed no evidence of such screening, education, or vaccine offering. This deficiency was identified through a review of the residents' electronic medical records. During an interview, the Director of Nursing confirmed that the facility did not have a process in place for screening residents' immunization status at admission, and no staff were responsible for this task. Additionally, there was no evidence that the residents or their responsible parties received education about the COVID-19 vaccine or were offered the vaccine. This lack of process and documentation led to the deficiency noted in the report.
Failure to Notify PCP of Medication and Treatment Lapses
Penalty
Summary
The facility failed to notify the Primary Care Physician (PCP) regarding significant lapses in medication and treatment administration for two residents. Resident 17 did not receive the prescribed medication Memantine for 13 days and was not provided with a CPAP machine for 15 days, as ordered. Additionally, Resident 17 was not assisted with walking as prescribed on multiple occasions. There was no evidence that the PCP was informed about these failures, which were confirmed by the Director of Nursing (DON). Resident 22 did not receive the prescribed Prednisone for several days due to unavailability, which was not communicated to the PCP. This resident experienced shortness of breath and was eventually hospitalized with a diagnosis of pneumonia. The DON confirmed that the PCP was not notified about the unavailability of the medication and the resident's subsequent condition.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to adhere to practitioner's orders for two residents, leading to significant deficiencies in care. Resident 17, who was admitted with multiple diagnoses including Alzheimer's disease and obstructive sleep apnea, did not receive prescribed Memantine medication for 13 out of 28 days due to unavailability. Additionally, the resident's CPAP machine, ordered for nightly use, was not provided for 15 out of 28 days. Furthermore, the resident was not assisted with walking as ordered, missing numerous scheduled ambulation times. The Director of Nursing confirmed these lapses, noting the absence of a policy related to following physician orders. Resident 22, with diagnoses including heart failure and respiratory failure, was prescribed Prednisone for respiratory issues but did not receive the medication for 8 out of 14 days due to pharmacy unavailability. This resident experienced worsening respiratory symptoms, including shortness of breath and diminished lung sounds, and was eventually hospitalized with pneumonia. The Director of Nursing acknowledged the medication was not available and confirmed the resident's subsequent hospitalization.
Failure to Document Antibiotic Duration for Two Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 16 and 19, had a documented duration of use for their long-term antibiotic therapy. The facility's Antibiotic Stewardship Program (ASP) policy requires that antibiotic orders include the indication, dose, and duration, and that the pharmacy consultant reviews and reports antibiotic usage monthly. However, the records for both residents showed continuous antibiotic administration without specified stop dates. Resident 16, who has moderate cognitive impairment and diagnoses including Parkinson's Disease and dementia, was receiving Bactrim DS for a urinary tract infection from April through December 2024. Similarly, Resident 19, with moderate cognitive impairment and a history of bladder infections, was receiving Keflex from June through December 2024. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the facility staff had reached out to the providers for education regarding the need for stop dates, but the antibiotics were continued without them. This oversight indicates a failure to adhere to the facility's ASP policy, which aims to optimize antibiotic use and reduce adverse events. The lack of documented stop dates for the antibiotics prescribed to Residents 16 and 19 represents a deficiency in the facility's medication management practices.
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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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| Heritage Of Bel Air | 0.7 mi | — | 0 | 0 |
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| Arbor Care Centers-countryside Llc | 13.8 mi | — | 16 | 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.