St. Ann's Community

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 09/04/2025 to 09/10/2025, for one (1) (3200 Unit) of two (2) medication carts reviewed, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal laws. Specifically, there were multiple pre-poured pills in six (6) unlabeled medication cups and all the pre-poured medications were signed off as given in the Medication Administration Record prior to administering them to the residents.

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 09/04/2025 to 09/10/2025, for one (1) (Resident #34) of one (1) resident reviewed, the facility did not ensure feeding assistants had successfully completed a State-approved training course that meets the requirements before feeding residents and feeding assistants provided dining assistance only for residents who have no complicated feeding problems. Specifically, Resident #34 who had a diagnosis of dysphagia (difficulty swallowing food or liquids) was observed receiving assistance with their breakfast meal from a staff member who had not completed an approved paid feeding assistant training program. Additionally, Resident #34's care plan did not reflect the use of a feeding assistant and the staff member was not under the direct supervision of a licensed nurse.

Inspectors wroteBased on interviews and record review conducted during a Recertification Survey, the facility did not ensure that newly admitted resident's and/or their representatives were provided with a written summary of a Baseline Care Plan that included the minimum healthcare information necessary to properly care for the immediate needs of the resident (including but not limited to initial goals, admission orders, dietary, therapy and social services) for 9 (Residents #2, #7, #31, #40, #53, #55, #56, #57 and #58) of 11 residents reviewed. Specifically for all residents identified the facility did not provide the resident or their representative with a summary of a Baseline Care Plan in a timely manner. This is evidenced by, but not limited to the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, for one (Residents #2) of one resident reviewed the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, Resident #2 had several extended periods of time without a documented bowel movement, did not receive appropriate interventions to manage their bowel patterns, and did not have a comprehensive care plan in place to address a diagnosis of constipation. This is evidenced by the following: The facility policy and procedure, Bowel Management, date 1/28/19 included that Nursing would monitor the bowel regimen where appropriate and establish a care plan to ensure the Elder (Resident) was having regular bowel patterns. The electronic documentation system bowel management report would be reviewed daily. [...]

Inspectors wroteBased on interviews, and record review conducted during the Recertification Survey and complaint investigation (#NY00327781), it was determined that for one (Resident #271) of six residents reviewed for unnecessary medications, the facility did not ensure that the resident was free from significant medication errors. Specifically, Resident #271 received an incorrect dose of a medication for Parkinson's disease for an extended period of time, in a dose that exceeded the recommended maximum daily dose and not as recommeded by the specialist. This is evidenced by the following: The facility policy and procedure, Internal and External Consults and Clinics, revised 7/25/22, included that any orders, reports, or notes received from an outside clinician upon return of the resident are given to nursing for review. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws for one (third-floor resident unit) of two medication rooms reviewed. Specifically, numerous controlled medications (drugs that are regulated by law due to their potential for abuse or addiction), including narcotics and opioids were observed unsecured and not in a double locked cabinet per the regulations. This is evidenced by the following. The facility policy Medications-Storage, Distributions, Administration and Wasting of Controlled Substances, dated 4/11/22 documented that controlled substances must be stored, distributed, and administered in a safe, secure manner with total compliance with all legal and regulatory requirements. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (Complaint # NY00323662) it was determined for one (Resident #1) of three residents reviewed for abuse the facility did not ensure the resident was free from the use of verbal, mental, or physical abuse. Specifically, Resident #1 was slapped on the abdomen, yelled at, and observed having a finger pointed in their face in an intimidating manner by a staff member. This is evidenced by the following: The facility policy, Elder Abuse/Neglect/Mistreatment Policy, dated 7/22/23, defined abuse as inappropriate physical contact with an Elder of a residential health care facility, while the Elder is under the supervision of the facility, which harms or is likely to harm the Elder. Inappropriate physical contact includes, but is not limited to, striking the Elder. [...]

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey completed on 8/29/22, it was determined that for two (Employees #2 and #4) of five employee files reviewed, the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, a nurse aide registry (NAR) abuse screening was not completed prior to new employees beginning work.

Inspectors wroteBased on observation and interviews conducted during the Recertification Survey completed on 8/29/22, it was determined that the facility did not ensure that the environment remained as free of accident hazards as possible. Specifically, on six of six resident care units, hazardous chemicals were stored in unlocked rooms and accessible to 57 residents including many with dementia and/or wandering behaviors. This is evidenced by the following: Review of facility policy Storage and handling of toxic and potentially hazardous chemicals, medications and treatment procedures, dated 12/22/94 included that the policy statement was to insure the protection and safety of elders/patients, all toxic and potentially hazardous chemical, medications, and treatment products will be store in designated locked areas when not in direct use. Section A: Cleaning Supplies #3: [...]

Inspectors wroteBased on observations, interviews, and record review, conducted during the Recertification Survey, completed on 8/29/22, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment for three of three residents reviewed. Specifically, Residents #3, #7, and #63 were observed on multiple days occupying wheelchairs with cracks, peeling material, and exposed padding. This is evidenced by: 1. Resident #7 had diagnoses including arthritis, osteoporosis, anxiety, and depression. The Minimum Data Set Assessment (MDS), dated [DATE], documented that Resident #7 was cognitively intact and required the use of a wheelchair. The resident also required extensive assistance from staff for transfers. During and observation and interview on 8/24/22 at 9:22 a.m., Resident #7 was sitting in a wheelchair. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey, completed on 8/29/22, it was determined that for one (Resident #40) of one resident reviewed for position/mobility and one (Resident # 23) of one resident reviewed for pressure ulcers, the facility did not review and revise the resident's care plan (with input from the resident or resident representative to the extent possible) to reflect the resident's current needs. Specifically, Resident #40's Comprehensive Care Plan (CCP) was not revised to reflect the discontinued use of hand splints and washcloths for hand contractures and Resident #23's CCP did not reflect the history of and current presence and treatment of existing pressure ulcer. This was evidenced by the following: [...]