St. Joseph Manor

F 0694

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review, the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 6 residents (Resident #2) reviewed for parenteral fluids The facility failed to ensure Resident #2's PICC line dressing was changed per physician orders. This failure could place residents with PICC line dressing at risk for potential infections.Findings included: Review of Resident #2's face sheet dated 09/04/2025 reflected a [AGE] year-old female admitted to the facility on [DATE REDACTED] with the following diagnoses: Staphylococcal arthritis, left knee, (infection of knee joint) sepsis (occurs when your immune system has a dangerous reaction to an infection) and methicillin susceptible staphylococcus aureus infection. Review of Resident #2's admission MDS dated [DATE REDACTED] 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.

Residents Affected - Few

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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Joseph Manor

2333 Manor Dr Bryan, TX 77802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Joseph Manor

2333 Manor Dr Bryan, TX 77802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Joseph Manor

2333 Manor Dr Bryan, TX 77802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

task (for example, placing an indwelling device or handling an invasive medical device); after contact with blood, body fluids, or contaminated surfaces; after touching a resident; after touching the resident's environment; before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal. 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.

1. 2. Wash and dry your hands thoroughly.

Event ID:

Facility ID:

If continuation sheet