St. Joseph Manor
St. Joseph Manor in Bryan, TX — inspection on September 4, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #2's admission MDS dated [DATE] reflected she was assessed to have a BIMS score of 15 indicating she was cognitively intact. Resident #2 was assessed to have the administration of IV medications.
Review of Resident #2's comprehensive care plan reflected a focus area dated 08/15/2025 for Resident is receiving intravenous (IV) medication for acute treatment.
Interventions included .monitor IV site every shift for signs of infiltration (leaking into the skin) .
Review of Resident #2's consolidated physician orders dated 09/04/2025 reflected an order dated 08/15/2025 to change PICC line dressing every week and PRN.
Review of Resident #2's TAR dated 08/2025 reflected an entry to change Resident #2's PICC line dressing every week.
The dressing change was due 08/31/2025 and it was signed off as done by LVN B.
Observation and interview on 09/04/2025 at 2:00 pm revealed Resident #2 in room in bed.
Observation of PICC line dressing revealed it was dated 08/24/2025, with no signs of infection. Resident #2 stated the site did not hurt, and she stated she did not know when the dressing was changed last. In an interview on 09/04/2025 at 3:30 PM the DON stated after review of Resident #2's TAR that Resident #2's PICC line dressing change was signed off as completed on 08/31/2025 by LVN B.
The DON stated LVN B obviously did not change the dressing if the dressing was dated 08/24/2025.
The DON stated it was not appropriate to sign off on doing a treatment and not completing the task and it was her expectation that PICC line dressing be changed per MD orders to prevent infections.
The DON provided LVN B's phone number and stated she would probably not answer because she was out of the country.
Attempt to contact LVN B on 09/04/2025 at 3:45 PM revealed no answer and no voicemail on phone number provided.
Review of the facility policy peripheral and midline IV dressing change dated 03/2022 reflected This purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings.
Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised Maintain sterile dressing (transparent semi-permeable membrane dressing or sterile gauze) for all peripheral catheter sites.
Change the dressing if it becomes damp, loosened or visibly soiled and: at least every 7 days.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
St.
Joseph Manor
2333 Manor Dr Bryan, TX 77802
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview and record review the facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 medication carts reviewed (station 1 medication cart).
The facility failed to ensure on 09/04/2025 that expired medications (one bottle of Melatonin 1mg expired 08/2025 and one bottle of Aspirin 325 mg expired 08/2025) were removed from the station one medication cart once expired.
This failure could place residents who received medications at risk of not receiving the intended therapeutic effect of the medications.Findings Included: Observation on 09/04/2025 at 2:30 pm of station one medication cart revealed a bottle of Melatonin 1mg expired 08/2025 and one bottle of Aspirin 325 mg expired 08/2025. In an interview on 09/04/2025 at 2:35 pm, LVN A stated it was the medication aide's responsibility to ensure expired medication are not on the cart, but they currently did not have one and since he was passing medications on the cart it was his responsibility to ensure the expired drugs were removed to ensure the residents do not get expired medications which could be less effective. In an interview on 09/04/2025 at 3:00 PM the DON stated both medications were expired and were removed from the medication carts.
The DON stated the staff should check the medication prior to administration to ensure the medications are not expired.
Review of the facility's policy medication labeling, and storage dated 02/2023 reflected The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls.
Only authorized personnel have access to keys.
The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
St.
Joseph Manor
2333 Manor Dr Bryan, TX 77802
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview and record review the facility failed to ensure storage of drugs and biologicals used in the facility for 1 of 4 medication carts reviewed (station 1 medication cart).
The facility failed to ensure medications were stored and used in an orderly manner to ensure the liquid did not run down the sides of the bottle causing it to be sticky on the sides of the bottle and the bottle was stuck to the bottom of the medication cart drawer.
This failure could place residents who received medications at risk of not receiving the intended therapeutic effect of the medications.
Findings Included: Observation on 09/04/2025 at 2:30 pm of station one medication cart revealed a bottle of lactulose in the medication cart drawer which was sticky on the sides of the bottle and the bottle was stuck to bottom of cart. In an interview on 09/04/2025 at 2:35 pm, LVN A stated the lactulose bottle was sticky and should have been cleaned. In an interview on 09/04/2025 at 3:00 PM the DON stated that staff should check the medication prior to administration to ensure the medications are stored properly.
Review of the facility's policy medication labeling, and storage dated 02/2023 reflected The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls.
Only authorized personnel have access to keys.
The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 5.
Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.
Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/04/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
St.
Joseph Manor
2333 Manor Dr Bryan, TX 77802
SUMMARY STATEMENT OF DEFICIENCIES
Review of the facility's policy wound care dated 10/2020 reflected The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. 1.
Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table.
Place all items to be used during procedure on the clean field.
Arrange the supplies so they can be easily reached.
- Wash and dry your hands thoroughly.
Facility ID: