Safety Report: St John Specialty Care Center
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
0Immediate jeopardy citations (severity J–L)
2Actual harm citations (severity G–I)
11Requirements cited on more than one inspection
G
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
G
Government finding: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F600
Citations by topic
12Abuse, neglect & exploitation
4Infection control
4Medications & pharmacy
4Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
More citations in the most recent cycle (29) than in the cycle before (13).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F600) | 5 | February 11, 2026; December 3, 2025; October 11, 2024; June 18, 2024; December 1, 2023 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 4 | February 11, 2026; October 11, 2024; July 9, 2024; June 18, 2024 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F657) | 3 | June 23, 2026; October 11, 2024; July 9, 2024 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 3 | October 11, 2024; December 1, 2023; June 16, 2023 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609) | 2 | February 11, 2026; June 18, 2024 |
| Provide and implement an infection prevention and control program. (F880) | 2 | October 11, 2024; December 1, 2023 |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. (F849) | 2 | October 11, 2024; December 1, 2023 |
| 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. (F761) | 2 | October 11, 2024; December 1, 2023 |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. (F622) | 2 | October 11, 2024; December 1, 2023 |
| Respond appropriately to all alleged violations. (F610) | 2 | June 18, 2024; December 1, 2023 |
| Provide safe and appropriate respiratory care for a resident when needed. (F695) | 2 | December 1, 2023; June 16, 2023 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| February 11, 2026 | Fine | $13,342 |
| February 11, 2026 | Fine | $13,342 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
June 23, 2026 — 1 citation · complaint investigation
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · complaint · corrected July 31, 2026
February 11, 2026 — 3 citations (includes serious) · complaint investigation
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected March 4, 2026
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Actual harm to a resident (not immediate jeopardy) · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected March 4, 2026
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected March 4, 2026
December 3, 2025 — 1 citation · complaint investigation
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected December 9, 2025
January 15, 2025 — 1 citation · complaint investigation
D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F580 · complaint · corrected February 14, 2025
October 11, 2024 — 24 citations
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected November 30, 2024
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected November 30, 2024
E
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F849 · corrected November 30, 2024
E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F690 · corrected November 30, 2024
D
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F944 · corrected November 30, 2024
D
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F942 · corrected November 30, 2024
D
Implement a program that monitors antibiotic use.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F881 · corrected November 30, 2024
D
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F810 · corrected November 30, 2024
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected November 30, 2024
D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F758 · corrected November 30, 2024
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F757 · corrected November 30, 2024
D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F742 · corrected November 30, 2024
D
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F691 · corrected November 30, 2024
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected November 30, 2024
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected November 30, 2024
D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F676 · corrected November 30, 2024
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · corrected November 30, 2024
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected November 30, 2024
D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F625 · corrected November 30, 2024
D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F623 · corrected November 30, 2024
D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F622 · corrected November 30, 2024
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · corrected November 30, 2024
D
Honor the resident's right to organize and participate in resident/family groups in the facility.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F565 · corrected November 30, 2024
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected November 30, 2024
July 9, 2024 — 2 citations · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected July 29, 2024
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · complaint · corrected July 29, 2024
June 18, 2024 — 6 citations · complaint investigation
E
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected June 28, 2024
E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected June 28, 2024
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected June 28, 2024
D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · complaint · corrected June 28, 2024
D
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F604 · complaint · corrected June 28, 2024
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · complaint · corrected June 28, 2024
December 1, 2023 — 12 citations
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected January 19, 2024
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected January 19, 2024
E
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F700 · corrected January 19, 2024
D
Report COVID19 data to residents and families.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F885 · corrected January 19, 2024
D
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F849 · corrected January 19, 2024
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected January 19, 2024
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected January 19, 2024
D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F622 · corrected January 19, 2024
D
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · corrected January 19, 2024
D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F600 · corrected January 19, 2024
D
Keep residents' personal and medical records private and confidential.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F583 · corrected January 19, 2024
D
Allow residents to self-administer drugs if determined clinically appropriate.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F554 · corrected January 19, 2024
June 16, 2023 — 5 citations
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected July 28, 2023
E
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F695 · corrected July 28, 2023
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · corrected July 28, 2023
D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F943 · corrected July 28, 2023
B
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
No actual harm, potential for minimal harm · Pattern · Administration Deficiencies · F949 · corrected July 28, 2023
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare