St. Johnsville Rehabilitation and Nursing Center

Inspectors wroteBased on observations, record review and interviews conducted during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life for two (2) (Resident #s 11 and 86) of 24 residents reviewed. Specifically, (a.) Resident #11 foley's catheter bag was exposed; (b.) Resident #86 heard Certified Nurse Aide #1 and Certified Nurse Aide #2 stated they had to wait and be the last one for care because they were so slow. Certified Nurse Aide #2 when asked to remove a raised toilet seat before Resident #86 used the bathroom, they replied, 'no, I am not breaking my back.' Resident #86 stated in both instances they were offended. [...]

Inspectors wroteBased on record review and staff interviews conducted during the recertification survey, the facility did not ensure that it maintained acceptable parameters of nutritional status, provided nutrition care and services to each resident consistent with the resident's comprehensive assessment for three (3) (Resident #s 6, 48, and 107) of seven (7) residents reviewed for nutrition/hydration status maintenance. Specifically, (a.) Resident #6 had a documented weight loss of 17.7 pounds in a month, (b) Resident #48 had a documented weight gain of 22.5 pounds in a month, and (c) Resident #107 had a documented weight loss of 35.6 pounds. The significant weight changes were not confirmed by reweights or addressed by the facility's dietician or medical providers. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification and abbreviated survey (Case # 2562681), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, residents reported that staff would not be able to provide them care for extended periods of time. Review of the actual staffing schedule revealed that on multiple occasions from 08/11/2025 to 09/01/2025, the facility staffing levels were below the facility assessment. This is evidenced by: The Facility Assessment, last reviewed in July 2025, documented that the facility's bed capacity was 120. The section titled, Staffing Plan, documented the following staffing needs based on a full facility census per day: [...]

Inspectors wroteBased on observations and interview conducted during the recertification survey, it was determined that the facility did not post nurse staffing information in an area accessible to all residents and visitors, as required by the posting requirements. Specifically, the posting of daily nurse staffing levels for staff working in the facility on each shift from 08/25/2025 through 09/03/2025 was located at the far end of the building. This is evidenced by: During observations from 8/25/2025 through 9/03/2025, the daily nurse staffing postings were located in a hallway at the far end of the building near the human resources office, which was not readily visible or accessible to all residents and visitors. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed five (5) percent for two (2) (Resident #s and 46) of two (2) residents observed during medication administration with 25 observations. This resulted in a medication error rate of 88 percent. This is evidenced by:The facility ' s Policy and Procedure titled, Medication Nurse Routine. Revised: 12/19/2024, documented all Medication Nurse duties are performed by licensed personnel. Procedures will be performed as follows by all staff uniformly. During the medication pass read orders from electronic medical record, Compare prescription label on blister pack to medication order. Remember the five (5) rights: a) right medication b) right resident c) right time d) right dose e) right route. Also check expiration dates. [...]

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure residents were free from significant medication errors for one (1) (Resident #8) of two (2) residents reviewed during a medication administration observation. Specifically, Licensed Practical Nurse #2 crushed and administered medications that were Do Not Crush for Resident #8. This is evidenced by:The facility's Policy and Procedure titled, Medication Nurse Routine, last revised 12/19/2024, documented all Medication Nurse duties are performed by licensed personnel. Procedures will be performed as follows by all staff uniformly. During the medication pass read orders from electronic medical record, compare prescription label on blister pack to medication order. Remember the five (5) rights: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for five (5) of five (5) medication carts reviewed. Specifically, (a.) two (2) narcotic lock boxes were broken; (b.) two (2) expired medications were found in medication room; (c.) three (3) bottles of eye drops had no open or expiration dates; and (d.) five (5) insulin pens did not have an open and/or expiration date. This is evidenced by:The facility's Policy and Procedure titled, Medication Storage, effective 03/21/2022 documented Medications housed on premises are stored in the medication rooms or medication carts according to the manufacturer's recommendations. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety in the main kitchen and two (2) of three (3) kitchenettes. Specifically, expired food was not discarded, a compatible test kit to measure concentration of chemical sanitizer used to manually sanitize food contact equipment (test kit) was not provided, food temperature thermometers were not calibrated, equipment was not in good repair, and equipment was not clean. This is evidenced by:During observations on 08/25/2025 at 10:17 AM: Thickened cranberry juice with use-by dates of 07/09/2025 & 08/12/2025 were found in the storeroom on the shelf with the common stock. The concentration of chemical sanitizer used to manually sanitize food equipment could not be checked; [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not maintain a pest-free environment and an effective pest control program in the main kitchen. Specifically, insect infestation was found in the main kitchen janitor closet. This is evidenced by:During observations on 08/25/2025 at 10:17 AM, small fruit flies were found in the janitor closet around the floor sink. The document titled; Pest Control Inspection Log and dated 02/27/2025 through 07/28/2025 documented that the facility was last treated for fly infestation on 02/27/2025. During an interview on 08/25/2025 at 11:06 AM, Assistant Director of Food Service #1 stated that the pest control vendor would be contacted to address the fly issue. New York Codes, Rules, and Regulations Title 10 S415.29(j)(5)

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated survey (Case # 684171), the facility did not ensure the residents' right to be free from abuse and neglect for two (2) (Resident #s 89 and 109) of two (2) residents reviewed for abuse and neglect. Specifically, (a.) on 6/10/2025, Resident #89 who was care planned to be observed closely when not in their room, was left unattended and struck Resident #109 with their walker; and (b.) on 6/22/2025, Resident #89 was sprayed in the face with hot sauce by Resident #63. This is evidenced by: The Facility's Policy titled; Resident Abuse Prevention, dated 05/2025, documented that the purpose was to provide residents, families, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution. [...]

Inspectors wroteBased on observations, record review and interviews during a recertification and abbreviated (Case #684171) survey, the facility did not ensure the facility implemented a comprehensive person-centered care plan for each resident for one (1) (Resident # 89) of 24 residents reviewed for comprehensive care plans. Specifically, supervision was not provided for the resident as directed by the comprehensive care plan for Resident # 89. This is evidenced by:The Policy and Procedure titled; Interdisciplinary Care Planning, last reviewed 4/16/2025, stated the interdisciplinary team would develop comprehensive care plans and the care plan must reflect intermediate steps for each outcome objective and staff would use these objectives to monitor resident progress. [...]

Inspectors wroteBased on observation, record review, and interview during the recertification survey, the facility did not ensure garbage and refuse was disposed properly. Specifically, the garbage dumpsters were not placed on hard & level surfaces, and one dumpster was not rodent proof. This is evidenced by:During observations on 08/25/2025 at 10:50 AM, 1 of 4 dumpsters did not have a drain plug and was not rodent proof, and four (4) of four (4) dumpsters were placed on gravel and dirt lawn and not on a hard & level surface (as stated on the directions posted on the dumpster). During an interview on 08/25/2025 at 11:06 AM, Assistant Director of Food Service #1 stated they would contact the maintenance department have hard level surfaces installed for the dumpsters and the missing drain plug installed. New York Codes, Rules, and Regulations Title 10 S415.14(h)Chapter 1 State Sanitary Code Subpart 14-1

Inspectors wroteBased on record review and interview during the recertification survey dated 7/13/2022 through 7/19/2022, the facility did not ensure foods brought to residents was in accordance with adopted regulations. Specifically, the facility did not provide information to families and other visitors on safe food handling practices, such as safe cooling and reheating processes, hot and cold holding temperatures, preventing cross contamination, and hand hygiene, of food that they bring to residents. This is evidenced is as follows: [...]

Inspectors wroteBased on observation, interview and record review during a recertification survey dated 7/13/2022 through 7/19/2022, the facility did not ensure residents had the right to self-administer medications if the interdisciplinary team, determined that this practice was clinically appropriate for 1 (Resident #223) of 1 resident reviewed. Specifically, the facility did not ensure Resident #223 was assessed to determine if self-administration of medication was clinically appropriate prior to leaving Symbicort (an inhaled medication used to treat wheezing and shortness of breath caused by breathing problems such as asthma or chronic obstructive pulmonary disease) at the resident's bedside for them to self-administer. This was evidenced by: Resident #223: [...]

Inspectors wroteBased on record review and interviews during the recertification survey dated 7/13/2022 through 7/19/2022, the facility did not ensure policies and procedures were developed and maintained for the monthly drug regimen review (DRR) that included timeframes for the different steps in the process. Specifically, the facility's DRR policy did not include timeframes for the facility staff and the attending physician to complete the review of reported irregularities requiring urgent action identified by the consultant pharmacist. This is evidenced by: The Policy and Procedure (P&P) titled Drug Regimen Review Policy dated 10/30/2018, documented irregularities identified during the pharmacy review process would be documented on a separate, written report, and sent to the attending physician, Medical Director, and Director of Nursing (DON). [...]

Inspectors wroteBased on observation, interview and record review during the recertification survey dated 7/13/2022 through 7/19/2022, the facility did not ensure it established and maintained 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 1 (Unit C) of 3 units. Specifically, the facility did not ensure staff wore gloves when touching contaminated items and surfaces, and performed hand hygiene immediately after removing their gloves, after contact with contaminated items, and before leaving a room, that they handled linen and wound care equipment in a manner that prevented the spread of infection, and that reusable equipment was sanitized after each use. This is evidenced by: [...]

Inspectors wroteBased on observation and interviews during the recertification survey dated 7/13/2022 through 7/19/2022, the facility did not ensure food was stored, prepared, distributed, or served in accordance with professional standards for food service safety for three (3) of 3 resident unit kitchenettes and the main kitchen. Specifically, microwave ovens, cabinetry, and floors in the A-Unit, B-Unit, and C-Unit kitchenettes and main kitchen were not clean and/or in good repair. This is evidenced as follows: During observations on 7/13/2022 at 10:45 AM, on the A-Unit, B-Unit, and C-Unit kitchenettes, the microwaves ovens were soiled with food particles. On the A-Unit and B-Unit kitchenettes, the floors and cabinetry were soiled with food particles or dirt. On the B-Unit kitchenette, the laminate was missing on the side of the counter above the ice machine exposing the raw particle board backing. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs for 6 (Resident #14, 43, 55, 110, 116, and 117) of 24 residents reviewed for comprehensive care plans (CCPs). Specifically, the facility did not ensure CCPs were developed and individualized and included person-centered interventions for Resident #14's diagnosis of sleep apnea and the use of a Bi-Pap (Bilevel Positive Airway Pressure) machine; for Resident #43's acute respiratory issue requiring oxygen, Prednisone, and nebulizer treatments; for Resident #95's broken dentures; [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. The contents of bulk food containers are to be labeled and food preparation and serving areas and equipment are to be kept clean. Specifically, equipment, floors, and ceilings in the main kitchen and 3 of 3 resident unit kitchenettes were not clean, and food was not served in a sanitary manner in the main dining room. This is evidenced as follows. The main kitchen and the satellite kitchenettes were inspected on 01/06/2020 at 10:06 AM. In the main kitchen, the microwave oven, slicer, can opener and holder, shelving, floor under equipment and next to walls, and ceiling tiles were soiled with food particles or grime. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that it maintained 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 two (Residents #'s 83 and 89) observed for wound dressings. Specifically, for Resident #89, the facility did not ensure that pressure ulcer dressing was done in a manner that prevented the spread of infection and the resident's Negative Pressure Wound Vacuum (NPWV) (a treatment modality that uses a vacuum to remove and contain wound drainage in a disposable container) was not kept on a soiled surface; and for Resident #83, that proper hand hygiene was performed who was on contact precautions. This is evidenced by: [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey the facility did not ensure a safe, clean, comfortable, and homelike environment, for 2 of 3 units. Specifically, for Unit's 1 and 2, the facility did not ensure that fall mats placed on the floor next to resident beds were not highly soiled, torn and tattered. This was evidenced by: During an observation on 1/7/20 and 1/9/20, of resident rooms 106, 116, 119, 120 and 221 foam fall mats were located next to the beds and were heavily soiled with dried material and were chipped, tattered and torn. In rooms [ROOM NUMBER], the foldable cushion mats covered with nylon like material were torn and heavily soiled with dried material. During an observation on 1/6/20 at 10:43 AM and on 1/7/20 at 10:50 AM, room [ROOM NUMBER]'s floor mat was torn and dirty. [...]

Inspectors wroteBased on interview and record review during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and the resident representative for 3 (Residents #'s 14, 55 and #106) of 3 residents reviewed for hospitalization. Specifically, the facility did not ensure there was documented evidence that the resident and the resident representative received written notice of the bed hold policy when the resident was transferred to the hospital. This was evidenced by: The Policy & Procedure (P&P) titled Bed Reservation/Retention dated 11/2019 did not include documentation that at the time of transfer of a resident for hospitalization or therapeutic leave, the facility provided the resident and the resident representative written notice which specified the duration of the bed-hold policy. Resident #14: [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey the facility did not ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 (Resident #'s 14, 43, 71, and #95) of 4 residents reviewed for respiratory care. Specifically, for Resident #'s 14 and 43, the facility did not ensure the residents' portable oxygen (O2) tanks did not run out of oxygen; for Resident #'s 43 and 71, that the resident's respiratory status was assessed before and after nebulizer treatments; [...]