St. John's Health Care Corporation

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for three (3) (Residents #120, #213 and #222) of seven (7) residents reviewed. Specifically, Resident #120 was observed with debris underneath multiple fingernails and eating food items with their hands. Resident #213 was observed over several days with greasy hair and the facility was unable to provide evidence of the resident getting their hair washed for the prior month. Resident #222 was observed with untrimmed overgrown mustache hair going into their mouth which they reported made them feel shameful about themselves and did not want visitors to see them in that state. [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility failed to ensure residents with indwelling urinary catheters (a tube inserted into the bladder to drain urine) received the care and services to manage the urinary catheter for two (2) (Resident #112 and #222) of four (4) residents reviewed. Specifically, Resident #112 had a urinary catheter that was not consistently secured to prevent tension resulting in a genital injury. Additionally, Resident #112's Comprehensive Care Plan did not include the presence of a urinary catheter or interventions for appropriate care of the urinary catheter to prevent complications. Resident #222 had a urinary catheter that was observed not secured appropriately to prevent complications. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, for one (1) (Resident #28) of one (1) resident reviewed, the facility did not ensure the interdisciplinary team determined the resident's right to self-administer medications was clinically appropriate. Specifically, there were multiple observations of unsecured medications left at Resident #28's bedside and the resident had not been assessed for their ability to self-administer medications. Additionally, there was no medical order or comprehensive care plan in place to address the self-administration of medications. The finding is: The facility policy Self-Administration of Medications, last reviewed 10/07/2008, included residents may self-administer medication when it has been determined by the interdisciplinary care team that the practice is safe. [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey and complaint investigations (NY00352162 and NY00356860) from 06/02/2025 to 06/09/2025 for 6 (Residents #23, #27, #93, #210, #313, #721) of 14 residents reviewed, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported to the New York State Department of Health in accordance with state law. Specifically, Resident #23 and #721 both had multiple unwitnessed falls including one with a major injury. Resident #27 had multiple bruises on their face of unknown origin. Resident #210 was observed by staff engaging in potential sexual abuse towards Resident #93. Resident #313 had an unwitnessed fall with a major injury and subsequently passed away within two (2) days. [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey and complaint investigations (NY00352162 and NY00356860) from 06/02/2025 to 06/09/2025 for 4 (Residents #23, #27, #313, #721) of 14 residents reviewed, the facility did not ensure that incidents were thoroughly investigated to rule out abuse, neglect, or mistreatment. Specifically, the facility was unable to provide documented evidence (including statements from all involved staff members or potential witnesses) that the following incidents were thoroughly investigated to rule out abuse, neglect, or mistreatment. Residents #23 and #721 had multiple unwitnessed falls with one fall resulting in a major injury for each resident. Resident #27 had multiple bruises to their face of unknown origin. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility did not ensure that person-centered comprehensive care plans were developed and/or implemented to address the resident's medical, physical, mental, and psychosocial needs for 7 (Residents #10, #110, #112, #122, #127, #199, and #236) of 40 residents reviewed. Specifically, Resident #10 had a diagnosis of diabetes and the comprehensive care plan did not include measurable goals or interventions related to diabetes. Resident #110 had a history of post-traumatic stress disorder, a history of suicide attempts, and a history of falls with injuries. The comprehensive care plan did not include measurable goals and interventions related to post-traumatic stress disorder, a history of suicide attempts, or falls. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility did not ensure that all drugs and biologicals were stored and/or labeled in accordance with currently accepted professional principles and regulations for six (6) of nine (9) medication carts and two (2) of six (6) medication rooms reviewed. Specifically, on Reservoir Three residential unit, there were pre-poured unlabeled medications for multiple residents and multiple unlabeled loose pills inside several medication carts, multiple medication cups containing several pills and medication creams left on top of the unsupervised medication cart, and the medication cart keys were left on top of the cart unattended. Additionally, there were expired medicated dressings in the Reservoir Three medication storage room. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025 for 8 (Reservoir 3rd, 5th, and 6th floors, [NAME] 1st floor, and South 2nd, 3rd, 5th, and 6th floors) of 20 resident use floors, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were dirty microwaves, a dirty refrigerator, outdated milk cartons, and a potentially hazardous food was not held at proper temperatures.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025 for one (1) (Resident #61) of 32 residents reviewed for dining, the facility did not ensure residents were treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of quality of life. Specifically, Resident #61 was observed having their blood sugar (measuring the amount of sugar in a blood sample from a finger-prick) tested and received an insulin injection and medications in the dining room with several residents, staff, and visitors present. The finding is: Resident #61 had diagnoses including diabetes, end stage renal (kidney) disease, and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, it was determined for 1 (Resident #120) of 32 residents reviewed for dining and 1 (Resident #222) of 2 residents reviewed for call bell accessibility, the facility did not ensure that a resident received services with reasonable accommodation of the resident's needs and preferences. Specifically, Resident #120 who was visually impaired reported to facility staff they needed assistance during meals. The resident was observed eating independently and there was no documented evidence the facility followed-up with the resident's request. Resident #222 was observed on several occasions without their call device within reach. The finding is: 1. [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #24) of four (4) residents reviewed for catheters. Specifically, there was no documented evidence that care of Resident #24's nephrostomy tube (tube inserted directly into the kidney through the skin to drain urine) was completed as ordered by the medical team.

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, for one (1) (Residents #2) of one (1) resident reviewed, the facility did not provide special eating equipment for a resident who required it to maintain or improve the resident's ability to drink independently. Specifically, Resident #28 was observed on multiple occasions without their two-handled cup as recommended by Occupational Therapy. The resident said it was difficult for them to consume beverages without it.

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) (Residents #112) of four (4) residents reviewed. Specifically, Resident #112 did not have Enhanced Barrier Precautions (EBP, techniques used to prevent transmission of infectious diseases utilizing gloves and gowns with all high contact care) signage outside their room and staff were observed providing hands on care without the appropriate personal protective equipment (gowns). [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 06/02/2024 to 06/09/2025, the facility did not ensure that a representative of the Office of the State Long-Term Care Ombudsman (an official patient advocate not hired by the facility) was notified of resident transfers or discharges including the reasons for the move in writing and in a language and manner they understand for three (3) (Residents #112, #217, and #314) of four (4) residents reviewed for discharges. Specifically, the facility did not notify the Office of the State Long-Term Care Ombudsman of Residents #112 and #117's transfers/discharges to the hospital and Resident #314's discharge to the community.

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey and complaint investigation (#NY00300345) from 12/6/23 to 12/13/23, for three (Residents #90, #108 and #183,) of six residents reviewed for pressure ulcers, the facility failed to ensure the residents received the necessary care, treatment, and services, consistent with professional standards of practice, to promote healing, prevent new pressure ulcers from developing, and/or prevent existing pressure ulcers from worsening. Specifically, the facility did not consistently provide Residents #90, #108 and #183 with physician-ordered treatments for skin impairments and/or care plan interventions. This resulted in actual harm to Resident #90 that is not Immediate Jeopardy. This is evidenced by the following: The facility policy Wounds: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey from 12/6/23 to 12/13/23, it was determined that for eight of nine medication carts reviewed for medication storage, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws. Specifically, multiple loose unlabeled pills were observed in the drawers of several medication carts ([NAME] 1, [NAME] 2, [NAME] 3 and Reservoir 6 cart 1) and medications were observed unlabeled and/or expired ([NAME] 1, Reservoir 4, Reservoir 5 and Reservoir 6 cart 2). The evidence included but not limited to the following: [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey completed 12/6/23 to 12/13/23, it was determined that for one of one main kitchen, and five (Reservoir fifth and sixth floors, [NAME] first and second floors, and South third floor) of twenty resident use floors, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, potentially hazardous foods were not cold held at or below 45 degrees Fahrenheit (°F), potentially hazardous foods were not properly cooled, there were undated and unlabeled food items, and a freezer had a significant buildup of ice.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey completed 12/6/23 to 12/13/23, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with Section 915 of the 2015 Edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide (CO) detection in a building that has fuel-burning appliances.

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification and complaint investigation (#NY00305787) completed 12/6/23 to 12/13/23, it was determined that for two (Residents #62 and #235) of five residents reviewed for dignity, the facility did not ensure that the residents were treated in a respectful and dignified manner. Specifically, Resident #62 was observed walking on the unit completely naked from the waist down with several other residents and multiple staff members in the vicinity and Resident #235 was observed to have multiple different pureed foods mixed together for their meal and fed to them by staff. This is evidenced by the following: 1. Resident #62 had diagnoses including dementia with behavioral disturbances a history of falls, anxiety, and depression. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey 12/6/23 to 12/13/23, it was determined that for 4 (South 3, South 4, Reservoir 4, Reservoir 6) of 11 resident care units reviewed, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, multiple resident wheelchairs, sit-to-stand lifts (assistive standing device), a shower mat, a resident reclining chair, and a dining room floor were observed soiled. This is evidenced by the following: During multiple observations on South 4 day shift on 12/6/23, 12/7/23, 12/8/23, 12/11/23 and 12/12/23 four wheelchairs, all occupied by residents had multiple dried food debris visible on them over three and four days. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey 12/6/23 to 12/13/23, it was determined that for two (Residents #99 and #182) of five residents reviewed for Minimum Data Set (MDS) Assessments (a mandated resident assessment tool) the facility did not assess the residents, using the Centers for Medicare and Medicaid Services (CMS) specified quarterly review assessment, no less than once every three months, between comprehensive assessments. Specifically, quarterly MDS Assessments were not completed within 92 calendar days from the prior MDS Assessment for both residents. Additionally, Resident #99's comprehensive MDS Assessment was also not completed in the required time frame. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 12/6/23 to 12/13/23, it was determined for two (Residents #48 and #52) of four residents reviewed for care planning related to respiratory care, the facility did not develop and/or implement a comprehensive, person-centered care plan for each resident that included services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as related to the need for respiratory care. Specifically Resident #48's Comprehensive Care Plan (CCP) did not include measurable goals, outcomes, and interventions for management of a tracheostomy (a surgically created hole in the windpipe that provided an alternative airway for breathing). Resident #52's CCP did not include measurable goals, outcomes, and interventions for use of oxygen (O2). [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey and complaint investigations (#NY00300019 and #NY305787) 12/6/23 to 12/13/23, it was determined that for three (Resident #84, Resident #90 and Resident #183) of nine residents reviewed for Activities of Daily Living (ADLs), the facility did not provide the necessary services to maintain grooming/personal hygiene, toileting and repositioning. Specifically, Resident # 84 did not receive assistance with removing facial and ear hair. Resident # 90 did not receive timely incontinence care, turning and positioning, and Resident #183 did not receive nail care. This is evidenced by the following: The facility policy Care: Standards of Care, dated last revised 8/22/23, included to shave men during morning care as per resident choice. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey from 12/6/23 to 12/13/23 it was determined for two (Resident #52 and #152) of four residents reviewed for respiratory care, the facility did not ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice, goals and preferences. Specifically, Residents #52 and #152 were observed with dirty oxygen (O2) tubing and/or humidification bottles (water bottles attached to the concentrator to provide moistened oxygen) not changed according to the physician's orders, and multiple missing documentation that the oxygen was being administered and/or equipment changed as ordered. This is evidenced by the following: The facility policy, Oxygen: [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification Survey and complaint investigation (#NY00300019) 12/6/23 to 12/13/23, it was determined that for one (Resident #83) of one resident reviewed, the facility did not ensure that the resident was free from significant medication errors. Specifically, the resident did not receive multiple medications on 12/10/23, which included (but not limited to) an anticoagulant or blood thinner used to prevent strokes, an antidepression medication used to treat insomnia or depression, a medication used to treat dementia or Alzheimer's disease and multiple prescription eye drops for glaucoma. This is evidenced by the following: [...]

Inspectors wroteBased on interviews, and record reviews conducted during the Recertification Survey and Complaint survey #NY00272037, completed on 11/8/21, it was determined that for one (Resident #155) of one resident reviewed for choices, the facility did not allow each resident the right to make choices about aspects of life that were significant to them. Specifically, the resident did not receive showers twice weekly per their plan of care and stated preference. This is evidenced by the following: Resident #155 had diagnoses including dementia without behavioral disturbance, intracranial injury, and overactive bladder. The Minimum Data Set Assessment, dated 9/2/21, revealed the resident was cognitively intact, required assistance with personal hygiene and bathing, was occasionally incontinent of bowel and bladder and had stated that type of bathing was very important to them. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey completed on 11/8/21, it was determined that for one of one resident groups and one of one residents (Resident # 112) reviewed, the facility did not ensure that concerns and recommendations of the residents group relating to resident care and life in the facility were acted on promptly. Specifically, residents' voiced concerns in the Residents Council meeting and a formal written grievance submitted by Resident #112, included long call bell wait times, not being provided personal care, and not being gotten up in a timely manner were not investigated and/or addressed in a timely manner. This is evidenced by the following: The facility policy, Grievances: Complaints/Grievances, last revised July 2020, included: The Social Worker will complete the Social Work Report of the Resident Concern form. [...]

Inspectors wroteBased on interviews, and record review conducted during the Recertification Survey completed on 11/8/21, it was determined that for one (Resident #55) of six residents reviewed the facility did not report incidents of resident-to-resident abuse to the State Agency per the regulations. Specifically, Resident # 55 was involved in multiple incidents of resident-to-resident altercations that were not reported to the New York State Department of Health (NYSDOH). This is evidenced by the following: The facility policy Abuse Prohibition, last revised March 2021, included that if after review of the information gathered during the in-house investigation the Director of Nursing (DON) and/or the Assistant DON (ADON) have reason to believe abuse, neglect or mistreatment had occurred then the DON or the ADON should submit an online report to the NYSDOH within two hours of making the determination. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey, completed on 11/8/21, it was determined for one (Resident #288) of two residents reviewed, the facility did not provide a program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of the resident. Specifically, there was no evidence of activities or psychosocial support for Resident #288 who was on isolation for COVID-19 infection. This is evidenced by the following: Resident #288 had diagnoses that included dementia, failure to thrive and COVID-19. The Minimum Data Set Assessment, dated 10/13/21, revealed the resident had severely impaired cognition, and activities of interest included music, going outdoors and being with groups of people. [...]

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification Survey and complaint investigation (NY00277696), completed on 11/8/21, it was determined for two of six residents the facility did not ensure that the resident's environment was free from accident hazards and each resident received adequate supervision to prevent accidents. Specifically, Resident #55 eloped due to inadequate staff response and a system failure, and Resident #276's multiple falls were not thoroughly investigated in order to make appropriate interventions to prevent accidents. This was evidenced by the following: 1. Resident #55 had diagnoses that included vascular dementia with behavioral disturbance, repeated falls and a history of wandering. [...]