Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Manor during CMS and state inspections, most recent first.
St. Joseph's Manor failed to notify the responsible parties of two residents about significant weight loss, contrary to their "Weight Management Guidelines." One resident with Alzheimer's dementia and dysphagia lost six percent of their weight in a month, while another resident with similar conditions lost 5.4 percent over two months. The facility's Administrator confirmed the lack of notification documentation.
The facility failed to follow physicians' orders for two residents with hypertension, administering medications outside prescribed blood pressure parameters. One resident received lisinopril despite low blood pressure, and another received metoprolol tartrate when their systolic blood pressure was below the specified limit. The administrator confirmed these errors.
St. Joseph Manor was found non-compliant with food safety standards, failing to store and serve food in a sanitary manner. Observations included debris in the ice cream freezer, improperly stored dry goods with scoops inside bins, and unlabeled and undated food items. The Director of Dietary Dining Services acknowledged the facility's policy violations.
The facility failed to maintain an adequate inventory of food and beverages for emergencies, as required by its facility-wide assessment and emergency preparedness plan. Observations and interviews revealed that the necessary food items were not available, and the dietary department confirmed the deficiency.
Failure to Notify Responsible Parties of Significant Weight Loss
Penalty
Summary
St. Joseph's Manor was found to be non-compliant with federal and state regulations regarding the notification of changes in resident conditions. Specifically, the facility failed to notify the responsible parties of two residents about significant weight loss. According to the facility's policy titled "Weight Management Guidelines," nursing staff are required to report unexplained significant weight changes to the family or responsible party. However, this protocol was not followed for two residents, identified as CL1 and 3, who experienced notable weight loss over a period of time. Resident CL1, who had Alzheimer's dementia and dysphagia, experienced a six percent weight loss from February to March 2025, dropping from 178.6 lbs to 167.8 lbs. Similarly, Resident 3, also diagnosed with dementia and dysphagia, lost 5.4 percent of their body weight between January and February 2025, with the weight loss persisting into March. Despite these significant changes, there was no documented evidence that the families or responsible parties of these residents were informed, as confirmed by the facility's Administrator during an interview.
Plan Of Correction
*What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? It has always been our policy and practice to notify families of significant change. In this case, the family was here each day with the resident and was up to date on the resident's condition. However, the nursing staff interacted with them verbally on a daily basis and they did not write nursing notes about those interactions. The patient is no longer at the center, so no further follow-up is needed for the resident. *How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? No other resident notification needs were identified during the recent audit. *What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? Staff in-service is being provided regarding: when to notify families, what constitutes a change in condition, and how to document those notifications. *How the corrective action will be monitored to ensure that the deficient practice will not recur, i.e., what quality assurance programs will be established? RNACS send out change of status (sig change notice) and other change of condition would be identified on shift reports. We will ask unit managers to monitor those and assure family is notified. DON or her designee will also monitor changes in condition and assure family was notified during morning clinical meeting.
Failure to Follow Medication Administration Parameters
Penalty
Summary
The facility failed to adhere to physicians' orders for two residents, resulting in the administration of medication outside the prescribed parameters. Resident 3, diagnosed with hypertension, had a physician's order to receive lisinopril once daily, provided their blood pressure was not below 110/65 mm/Hg. However, the medication administration records (MARS) indicated that the medication was given once in March and twice in April when the resident's blood pressure was below the specified threshold. Similarly, Resident 5, also diagnosed with hypertension, was prescribed metoprolol tartrate twice daily, with the condition that it should not be administered if the systolic blood pressure was below 100 mm/Hg. Despite this, the MARS showed that the medication was administered four times in April when the resident's systolic blood pressure was below the prescribed limit. The facility's administrator confirmed these discrepancies during an interview.
Plan Of Correction
*What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? No negative signs or symptoms related to medications provided outside parameters were identified. Physician will be notified of these occurrences. Med errors will be reported in QAPI. Nurses who were non-compliant will be coached or disciplined. *How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? An audit of medications with parameters will be completed to assure no additional residents received medications outside the parameters ordered. *What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? All licensed nursing staff will be in-serviced to pay attention to medication parameters when administering medications and to follow those orders. All parameters are included on the MAR to assure they are easily visible to nurses to comply with at time of medication administration. *How the corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? DON and Unit Managers or their designee will complete audits of residents with medications containing parameters monthly. These will be completed for the next 4 months to assure nursing is consistent with the following parameters. Pharmacy consultant will also be asked to randomly audit the MAR for medication parameter compliance. Any noncompliance identified will be addressed with coaching and or disciplinary action.
Non-Compliance with Food Safety Standards
Penalty
Summary
St. Joseph Manor was found to be non-compliant with food safety requirements as per 42 CFR Part 483, Subpart B, and the 28 Pa. Code. The facility failed to store and serve food in a sanitary manner, which could potentially lead to foodborne illness. During a kitchen tour, debris was observed at the bottom of the stand-up ice cream freezer. Additionally, four bins containing dry goods such as white rice, flour, thickened liquid product, sugar, and brown rice had scoops stored inside them, directly on top of the dry goods. A container of whipped cream in the refrigerator was neither labeled nor dated. In the dry goods storage room, several food items were found opened and re-sealed without proper labeling or dating, including a bag of cereal, spaghetti, penne pasta, long grain rice, and tortilla chips. A box of kosher salt was opened and stored unsealed and undated on a shelf, alongside a container of Old Bay seasoning that was opened, without a lid, and undated. The Director of Dietary Dining Services confirmed that all opened food should be re-sealed, labeled, and dated, and that scoops should not be stored inside the dry storage bins.
Plan Of Correction
All food items will be properly sealed, stored, labeled and dated. Food service staff will be in-serviced on proper food storage, labeling, and dating of food. Each food service worker will sign the in-service training form to acknowledge their understanding of the policies and procedures for food storage and handling. Director of Dining Services or designee will audit all food storage areas at least weekly to assure compliance of food storage and handling. The audit results will be retained by Dining Service Director for review by QAPI and NHA. The audit forms will be submitted to the QAPI committee for the next six months. Any compliance challenges identified in this area will be immediately addressed by the Dining Service Director. A compliance book will be created and will hold: - Copies of staff training on food storage, labeling and dating - Food storage area audit sheets - Weekly (one audit sheet for each area, each week) - Report for monthly QAPI meeting reflecting ongoing compliance
Inadequate Emergency Food Supply Inventory
Penalty
Summary
The facility failed to implement its facility-wide assessment to ensure an adequate inventory of resources, specifically sustenance, food, and beverages, in the event of an emergency or disaster. The facility assessment dated January 22, 2025, indicated that the facility was responsible for maintaining a documented inventory of resources necessary for emergencies. However, upon review, it was found that the facility did not adhere to this requirement as outlined in their emergency preparedness plan. The emergency preparedness plan required the facility to ensure adequate sustenance needs for residents and staff during emergencies. Additionally, the facility's "Food and Nutrition Disaster Plan," last reviewed on March 8, 2024, outlined procedures for preparedness, including maintaining an inventory of both perishable and non-perishable food supplies. This inventory was supposed to cover all current service points and additional staff and visitors. During an observation in the kitchen on February 11, 2025, and a review of facility documentation, it was revealed that the required number of food items listed in the facility's par listing were not available. Interviews with the general manager of the dietary department and the Administrator confirmed that the facility did not have the necessary food and beverage supplies on hand as per the facility assessment, emergency preparedness plan, and dietary policy and procedure.
Plan Of Correction
A 4-day disaster menu will be maintained. All food items needed to implement the emergency menu will be kept in the food storage areas. The facility always keeps 7-days of food in house in the main kitchen. Additionally, a 3-day emergency stock specific to the emergency menu is kept in designated areas of the food storage. All foods required to feed staff and residents of the facility for 3 days is available on premises at all times. A food inventory sheet with required par level/ portions will be updated weekly as stock is rotated and ordered by the Head Chef or designee. Each week the inventory sheets will be signed, dated and retained by the Dining Service Director. The Dining Service Director will be responsible to assure emergency food supplies are always adequate for the facility staff and residents. Training will be provided to the Food and nutrition general services manager, head chef, dining services managers and other key managers regarding the emergency supplies requirements and process. Each month the inventory levels will be reported to the QAPI team for the next six months. A compliance book will be created and will hold: - 4-day Emergency Menu - Emergency Food Inventory- Weekly - Training for key administrative staff on emergency supplies - Report for monthly QAPI meeting reflecting ongoing compliance
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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.