St. Johnland Nursing Center

Inspectors wroteBased on observation, interviews and record review during an abbreviated survey intake number 2707253 the facility failed to ensure adequate supervision and timely risk assessment for an elopement for one (1) of three (3) sampled residents (Resident #1). Specifically, Resident #1 verbalized the desire to leave the facility to a provider who reported it to facility staff, the facility failed to follow the elopement prevention policy and assessed for elopement risk or implement supervision. Resident #1 eloped from the facility and was found outside on the facility grounds 30 minutes later.

Inspectors wroteBased on observation, record review, and interviews during the abbreviated survey 2645588 , the facility did not ensure the residents right to be free from abuse and neglect for one (Resident #1) of three residents reviewed. Specifically, during a transfer Certified Nursing Assistant #1 needed to lower Resident #1 to the floor when their (Resident #1) legs became weak. This resulted in an injury to Resident #1's left knee requiring first aid. Certified Nursing Assistant #1 completed the transfer by themselves although the comprehensive care plan and Kiosk Nursing instructions documented Resident #1 was to have two staff member assistances with transfers. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00372994 and NY00364939) the facility did not ensure that resident's received adequate supervision to remain free from sexual abuse for three (3) of three (3) residents (Resident #2, #3, and #4) reviewed for abuse. Specifically, on 12/16/2024 at approximately 8:00 AM, License Practical Nurse #2 responded to a call for help from the dining room and observed that Resident #1 was touching the genital area of Resident #2. License Practical Nurse #2 intervened and removed Resident #2. Resident #1 was left unsupervised and immediately began rubbing the genital area of Resident #3. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00358060, NY 00355385, NY 00357476, and NY 00358655) initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. This was identified for four (Inn, Head Injury Rehabilitation Unit, Muhlenberg, and [NAME] Hall) of seven nursing units reviewed during the Sufficient Nursing Staffing Task. Specifically, during an observation on 12/8/2024 (Sunday) 13 of 15 residents in the Head Injury Unit were still in bed at 11:38 AM due to insufficient staffing. Resident #38, who resided in the Inn unit, did not receive showers as scheduled on 11/28/2024 and 12/2/2024 due to understaffing. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen task observation on 12/4/2024. Specifically, the facility did not monitor the temperature of cold food items (sandwiches, potato salad, pudding) at the time of meal service. The finding is: A facility policy and procedure titled Food Preparation, documented time/temperature control for safe food (formerly known as potentially hazardous food) means a food that requires time/temperature controls for safety to limit pathogenic organism growth or toxin formation. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure each resident was treated with respect and dignity and provided care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. This was identified on one ([NAME] Unit-secure dementia unit) of seven nursing units observed during the dining task. Specifically, during the lunch meal observation on 12/4/2024 on the [NAME] unit, there were 11 dining tables in the room. At least 3 to 4 residents were seated at each table. The lunch meal was being served by the nursing staff from the first meal transport rack. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure it developed and implemented a comprehensive person-centered care plan for each resident to meet each resident's medical and nursing needs. This was identified for one (Resident #152) of one resident reviewed for Accommodation of Needs. Specifically, Resident #152 had a physician's order for a wheelchair with bilateral leg rests. Resident #152 was observed on multiple occasions sitting in the wheelchair without the leg rests. The finding is: The facility's policy titled Wheelchair Safety, effective March 2017, documented you must never transport a resident without foot pedals regardless of locomotion status. Make sure feet are on foot pedals when the resident is in the wheelchair. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification initiated on 12/3/2024 and completed on 12/10/2024, the facility failed to ensure, to the extent practicable, the participation of the resident and the resident's representative(s) for the development of the resident's care plan. This was identified for one (Resident #66) of three residents reviewed for Care Planning. Specifically, the facility did not conduct interdisciplinary care plan meetings and did not provide notice of invitation to the resident or the resident's representative to participate in the quarterly assessments. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated survey (NY 00361065) initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure the resident environment remained as free of accident hazards as possible and the residents received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #73) of six residents reviewed for Accidents. Specifically, Resident #73 required two-person assistance with bed mobility and for a mechanical lift transfer to and from the bed. On 11/18/2024, Certified Nursing Assistant #14 turned and positioned Resident #14 by themselves and used a mechanical lift transfer to transfer Resident #73 from bed to their wheelchair without assistance. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated survey (NY 00361065) initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for resident needs, This was identified for one (Resident #73) of six residents reviewed for Accidents. Specifically, Resident #73 required two-person assistance with bed mobility and mechanical lift transfers. On 11/18/2024, Certified Nursing Assistant #14 turned and positioned Resident #14 by themselves and used a mechanical lift transfer to transfer Resident #73 from bed to their wheelchair without assistance. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey initiated on 12/3/2024 and completed on 12/10/2024, the facility did not ensure that all medications and biologicals were stored properly and labeled in accordance with currently accepted pharmaceutical principles and practices. This was identified for one (Resident #19) of six residents reviewed for Accidents. Specifically, the facility did not ensure that medications were properly labeled and stored. Two tubes of Voltaren analgesic cream, which were not labeled with the resident's name or directions of application, were observed in Resident #19's room on their nightstand. There was no staff in the vicinity.

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 12/3/2024 and completed 12/10/2024, the facility did not ensure each resident was provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, taking into consideration the preferences of each resident. This was identified for one (Resident #79) of three residents reviewed for Food. Specifically, Resident #79 verbalized disliking the food served to them and specified they were not assessed for their food preferences.

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/10/2024, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #46) of five residents observed during medication administration. Specifically, during the medication administration observation for Resident #46 on 12/4/2024, Registered Nurse #1 handled the oral medication tablets with their bare hands and administered those medications to the resident. The finding is: The facility's policy titled Medication Pass via Medication Cart, dated 12/2016, documented to follow infection control policies while administering medication. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey and abbreviated Survey (NY 00358655) initiated on 12/03/2024 and completed on 12/10/2024, the facility did not ensure call bells were within reach for each resident at their bedside. This was identified for one (Resident #39) of five residents reviewed for Activities of Daily Living. Specifically, Resident #39, who was assessed to require assistance with transfer and locomotion, was observed on several occasions with a tap call bell out of reach. The finding is: Resident #39 was admitted with diagnoses including Traumatic Brain Injury, Anoxic (lack of oxygen) Brain Injury, and Myocardial Infarction (heart failure due to lack of blood supply to the heart). [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey and Abbreviated survey (Complaint #NY00278415) initiated on 5/11/2023 and completed on 5/18/2023, the facility did not ensure that each resident received assistive devices to prevent accidents. This was identified for one (Resident #124) of nine residents reviewed for accidents. Specifically, Resident #124, who was cognitively intact was pushed by Physical Therapist (PT) #1 from the patio to the resident's room on 6/21/2021. PT #1 pushed the wheelchair without the leg rests in place contrary to the facility's leg rest policy. Subsequently, Resident #124's left leg got caught under the wheelchair. Resident #124 was transferred to the hospital and was diagnosed with a left femur (thigh bone) fracture. This resulted in actual harm to Resident #124 that is not Immediate Jeopardy. The finding is: [...]

Inspectors wroteBased on interviews, and record review during the Recertification Survey and Abbreviated survey (Complaint # NY00315350) initiated on 5/11/2023 and completed on 5/18/2023, the facility did not ensure that each resident remained free from abuse. This was identified for one (Resident #142) of two residents reviewed for abuse. Specifically, a Certified Nursing Assistant (CNA) #3 was observed hitting Resident #142's shoulder, waiving a phone directly in front of the resident's face, and speaking in a loud manner while accompanying the resident to a medical appointment outside of the facility. The finding is: The facility's Policy and Procedure titled Abuse, Identification, Investigation and Reporting dated 10/2016 and last revised on 4/2023, defined physical abuse as inappropriate physical contact with a resident which harms or is likely to harm the resident. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00303861) initiated on [DATE] and completed on [DATE] the facility did not ensure that services provided or arranged by the facility meet professional standard of quality. This was identified for one (Resident #356) of two residents reviewed for accident. Specifically, Resident #356 was readmitted on [DATE] on the 3:30 PM-to 11:30 PM shift with diagnoses of Head Injury and Chest Contusion. The resident was placed on the 24-Hour Report for monitoring. There was no documented evidence in the medical record that the resident was assessed on the 11:30 PM-7:30 AM shift. The finding is: The facility's Admission/readmission Vital Signs policy and procedure last reviewed 1/2023 documented for all admission and readmission to have regular monitoring of vital signs. [...]

Inspectors wroteBased on interviews and record review during a Recertification Survey and an Abbreviated Survey (Complaint# NY00289075) initiated on 5/11/2023 and completed on 5/18/2023 the facility did not ensure that each resident who is unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain safe transfers. This was identified for one (Resident #18) of five residents reviewed for ADLs. Specifically, Resident #18 was assessed as at risk for falls and required two-person assistance for transfers to and from the bed as per the resident's plan of care. On 12/31/2021 Certified Nursing Assistant (CNA) #4 transferred Resident #18 by themselves from a chair to the bed causing Resident #18 to fall during the transfer. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 5/11/2023 and completed on 5/18/2023, the facility did not ensure that it maintains medical records for each resident that are complete and accurately documented. This was identified for one (Resident #74) of one resident reviewed for Dialysis. Specifically, the Physician's monthly notes dated 4/17/2023 and 5/11/2023 did not address the resident's right upper extremity Deep Vein Thrombosis (DVT) status. The finding is: The facility's Physician Services policy and procedure dated 12/2022 documented that the Physician must review the resident's total program of care, including medications and treatments, at each visit. Resident #74 was admitted with diagnoses that include End Stage Renal Disease (ESRD) on Hemodialysis, Acute Embolism and Thrombosis of Deep Vein of Right Upper Extremity, and Hypertension. [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 5/11/2023 and completed on 5/18/2023, the facility did not ensure that an Infection Prevention and Control Program (IPCP) designed to help prevent the development and transmission of infection was maintained. This was identified for one (Resident #147) of five residents reviewed for Pressure Ulcers. Specifically, during a wound care observation for Resident #147's Stage III Pressure Ulcer, the Licensed Practical Nurse (LPN) #3 did not perform hand hygiene after cleansing the wound and prior to donning (putting on) clean gloves. The finding is: The facility's Policy and Procedure for Hand Hygiene dated 12/2022 documented to apply new gloves and perform hand hygiene. Resident # 147 has diagnosis that include Stage III Pressure Ulcer to the sacral region. [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification survey completed on 4/13/2021, the facility did not provide pharmaceutical services, including procedures that assure accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident on 3 of 7 nursing units. Specifically, the emergency boxes in the medication rooms had expired medications.