St. Patrick's Home

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, interviews with residents, resident representatives, and staff members indicated that there were staffing concerns in the facility. Additionally, a review of staffing from 11/02/2024 -12/08/2024, from 01/01/2026-03/31/2026, and from 06/22/2026 -06/29/2026 indicated multiple dates where the facility did not ensure sufficient nursing staffing based on their facility assessment's staffing levels. The Payroll Based Journal Staffing Data Report for 01/01/2026-03/31/2026 triggered for One Star Staffing Rating and excessively low weekend staffing.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that the resident and the resident representative were promptly notified when there was a need to alter treatment significantly (that is, a need to adjust an existing medication, and to commence a new form of treatment). This was evident for one of one resident (Resident #33) reviewed for Notification of Change out of a sample of 36 residents. Specifically, the facility failed to notify Resident #33's representative when medication was discontinued. Number of residents sampled: 1Number of residents cited: 1.

Inspectors wroteBased on observation, record reviews, and interviews during survey, the facility failed to ensure that a resident was free from physical abuse. This was evident for one (Resident #1) of four residents reviewed for abuse. Specifically, on 05/27/2025 at 10:10 PM, Resident #1 reported that Certified Nursing Assistant #1 hit them on their nose and grabbed their hand. Registered Nurse Supervisor #1 assessed Resident #1 and noted Resident #1 had a 2-centimeter skin tear on the left arm and a swollen nose bridge. Resident #1 received Tylenol 650 milligrams for pain and was transferred to the hospital on [DATE] at 12:00 AM for evaluation. Resident #1 did not return to the facility. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY 00338277), the facility failed to protect residents from sexual abuse by nursing home staff. This was evident in two out of ten residents (Resident #1 and Resident #2) sampled for sexual abuse. Specifically, 1. On 04/06/24 at approximately 1:00 pm Resident #1 reported to Certified Nursing Assistant #1 that an Asian man (alleged perpetrator) entered their room and asked Resident #1 to see their hernia; the alleged perpetrator grabbed and fondled Resident #1's penis. Resident #1 reported the sexual abuse occurred on 04/06/24 at 10:00 am. Subsequently during an interview with Resident #1 on 04/16/24 at 12:19 pm, they stated at the time of the incident they were scared. 2. [...]

Inspectors wroteF609 S/S=E Based on observation, record review, and interviews conducted during an abbreviated survey (NY00338277), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, and mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident in two out of four residents sampled (Residents #1 and #2). Specifically, 1. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00338277) the facility did not report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident in two out of four residents sampled (Residents #1 and #2). Specifically, 1. On 04/06/24 at approximately 1:00 pm Resident #1 reported to Certified Nursing Assistant #1 that an Asian man (alleged perpetrator) entered their room and asked Resident #1 to see their hernia and then the alleged perpetrator grabbed and fondled Resident #1's penis. Resident #1 reported that the sexual abuse occurred on 04/06/24 at 10:00 am. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification and complaint (NY00310433 and NY00316167) survey from 2/8/2024 to 2/15/2024, the facility did not ensure residents received adequate supervision to prevent accidents. This was evident for 2 (Resident #11 and #149) of 6 residents reviewed for accidents out of 39 total sampled residents. Specifically, 1) Resident #11, who is cognitively impaired with agitated behaviors, sustained a laceration on the left lower and upper leg when being transferred from chair to bed; 2) Resident #149, a cognitively impaired resident, did not receive adequate supervision and interventions to prevent seven falls in eight months.

Inspectors wroteBased on observation, record review, and staff interviews conducted during the recertification/complaint survey, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for 2 (8th and 5th Floors) of 6 resident units. Specifically, 1) Licensed Practical Nurse #2 did not sanitize a blood pressure cuff in between resident use, and 2) Licensed Practical Nurse #6 did not sanitize a glucometer in between resident use.

Inspectors wroteBased on record review and interviews conducted during the recertification and abbreviated (NY00316167) survey from 2/8/2024 to 2/15/2024, the facility did not ensure all alleged violations involving an injury of unknown origin were reported immediately, but not later than 2 hours after the allegation was made, to the New York State Department of Health. This was evident for 2 (Resident #34 and #149) of 39 total sampled residents. Specifically, 1) Resident #34 was found to have a left upper arm fracture of unknown origin that was not reported to the New York State Department of Health, and 2) the facility did not report an unwitnessed incident resulting in a hematoma to Resident #149's head to the New York State Department of Health.

Inspectors wroteBased on record review and interview conducted during the Recertification survey from 2/8/2024 to 2/15/2024, the facility did not ensure that resident comprehensive care plans were reviewed and revised after each assessment. This was evident for 2 (Resident #106 and #160) of 39 total sampled residents. Specifically, 1) the care plan related to Resident #106's pain management was not reviewed and revised upon assessment, and 2) the care plan related to Resident #160's anticoagulant use was not reviewed and revised upon assessment.

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey, the facility did not ensure that individual financial records were available to the resident through quarterly statements. Specifically, a resident did not receive quarterly statements in July 2021 and October 2021. This was evident for 1 out of 1 residents reviewed for Personal Funds out of a sample of 31 residents. (Resident # 32). The finding is: The facility policy Patient Trust Funds, revised January 2019, documented quarterly statements of resident's funds will be distributed to the resident's responsible party. The policy documented it is the responsibility of the administrator and executive director to ensure the resident trust accounts are in compliance with corporate and regulatory policy. [...]

Inspectors wroteBased on observation, interviews and record reviews conducted during a recertification survey the facility did not ensure that a person-centered, comprehensive care plan was developed and implemented to meet a resident's concerns and address the resident's medical, physical, mental and psychosocial needs. Specifically, a resident had a physician order for a Wander Guard but no current care plan in place to address wandering or elopement. This was evident for 1 out of 1 residents reviewed for wandering/elopement out of a sample of 34 residents. (Resident # 66).

Inspectors wroteBased on observation, interviews and record reviews conducted during a recertification survey the facility did not ensure that a resident received adequate supervision to prevent accidents. Specifically, a Certified Nursing Assistant (CNA) did not follow the plan of care for a resident to provide necessary supervision during toileting. The CNA left the resident, who was confused and had a known history of falls, alone on the toilet, and the resident subsequently fell. This was evident in 1 of 4 residents reviewed for Accidents out of a sample of 34 residents. (Resident #66).

Inspectors wroteBased on observations, record review and staff interviews conducted during a recertification survey the facility did not ensure that a nurse's aide was able to demonstrate competency in skills and techniques necessary to care for a resident's needs as identified through resident assessment and described in the plan of care. Specifically, a Certified Nursing Assistant (CNA #2) who had received training in falls prevention was assisting a resident with toileting and left the resident alone on the toilet without ensuring the resident's safety. The resident fell and sustained a minor injury. This was evident in 1 of 1 residents reviewed for Staff Competency out of a total sample of 34 residents. (Resident #66).

Inspectors wroteBased on record review and interviews conducted during the recertification survey, the facility did not ensure that advance directives were provided to residents and their families. Specifically, Advance Directives were not reviewed periodically with residents or family representatives. This was evident for 4 of 4 residents reviewed for Advanced Directives (Resident #69, #225, #97 and #188)

Inspectors wroteBased on record review and interview conducted during the Recertification Survey, the facility did not ensure that residents received proper notification prior to being discharged from skilled services. Specifically, a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) {Form CMS-10055} was not provided to the resident prior to termination of services. This was evident for 1 of 3 residents reviewed for the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review out of a sample of 38 residents. (Resident #203).

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure a resident was free from physical restraints. Specifically, a resident was observed multiple times, sitting on a wheel chair with a long table in front of her, close to a wall that prevented the resident from rising out of the chair. This was evident for 1 of 1 resident reviewed for Physical Restraints out of a sample of 38 residents. (Resident # 94) The finding is: The facility policy titled Restrictive Devices/Equipment (Formerly known as Physical Restraint) dated 06/18/1998 documented a restrictive device/equipment shall be used without disregard for the resident's dignity, comfort, the capacity to perform a useful physical function, the ability to participate in a recreational or psychosocial stimulation, and the need to be safeguarded from injury. [...]

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, a Level 2 Preadmission Screening and Resident Review (PASRR) for serious mental illness was not documented in the Minimum Data Set (MDS) assessment. This was evident of 1 out of 1 residents reviewed for PASRR out of a sample of 38 residents. (Resident #57).

Inspectors wroteBased on observation, interviews and record review conducted during the recertification survey, the facility did not ensure that comprehensive person-centered care plans, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs were developed. Specifically, comprehensive care plans were not developed for residents receiving comfort care. This was evident for 2 of 2 residents reviewed for Hospice and End of Life out of 38 sampled residents. (Resident #158 & 124). [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that the attending physicians reviewed the residents total program of care on each visit that is required by this regulation. Specifically, the attending physician, did not identify the practice of positioning the resident at a table in a way that restricted movement as a physical restraint and did not provide evaluations of ongoing restraint use for a resident. This was evident for 1 of 1 resident reviewed for Physical Restraints out of a sample of 38 residents. (Resident # 94) The finding is: [...]

Inspectors wroteBased on observation, record reviews, and staff interviews conducted during the recertification survey, the facility did not ensure a resident was free from unnecessary psychotropic medications. Specifically, a resident with diagnoses of Dementia and no history of psychiatric diagnoses, was prescribed psychotropic drugs without an appropriate indication. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a sample of 38 residents. (Resident #94)