Provider Name: ST JOSEPH MANOR
Address: 2333 MANOR DR, BRYAN, TX 77802
Phone: (979) 821-7330
County: Brazos (190)
Ownership Type: Non profit - Corporation
Certified Beds: 81
Average Residents Per Day: 57.5 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: BURLESON COUNTY HOSPITAL DISTRICT
First Approved Date: September 20, 2001
Affiliated Entity: ()
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 5 ()
Health Inspection Rating: 4 ()
QM Rating: 4 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: 4 ()
Staffing Rating: 5 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.34096, LPN Staff Hours Per Day: 1.1482, RN Staff Hours Per Day: 0.7901, Licensed Staff Hours Per Day: 1.9384
Total Nurse Staff Hours Per Day, per resident: 4.27939
Weekend Nurse Staff Hours: 3.67603, Weekend RN Staff Hours: 0.4824
PT Staff Hours Per Day, per resident: 0.0556
Nurse Staff Turnover: 19.6, Nurse Turnover Note:
RN Turnover: 10.0, RN Turnover Note:
Admin Left Number: , Admin Turnover Note: 6
Case Mix Nurse Aide Hours Per Day, per resident: 1.9977, Case Mix LPN Hours Per Day: 0.6858, Case Mix RN Hours Per Day: 0.3231
Adjusted Nurse Aide Hours Per Day, per resident: 2.38721, Adjusted LPN Hours Per Day: 1.2354, Adjusted RN Hours Per Day: 0.9213
Total Adjusted Nurse Hours Per Day, per resident: 4.48607
Adjusted Weekend Nurse Hours Per Day, per resident: 3.85358
Health Survey Dates and Scores: Cycle 1: 2022-12-08 (Score: 36), Cycle 2: 2021-09-10 (Score: 24), Cycle 3: 2019-04-03 (Score: 24)
Total Weighted Health Score: 30.000
Reported Incidents: 1, Substantiated Complaints: 0
Infection Control Citations: 0
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 12649.00, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 2333 MANOR DR,BRYAN,TX,77802 (30.6593, -96.351)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-12
Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-12
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-12
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-12
Type: Health, Deficiency: Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-09
Type: Health, Deficiency: Make sure that a working call system is available in each resident's bathroom and bathing area.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-12
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Past Non-Compliance on 2022-10-05
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-09-17
Type: Health, Deficiency: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-03
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-03
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0741, Version: New
Description: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-20
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-23
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-17