St. Joseph's Hospital - Skilled Nursing Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not provide maintenance services necessary to maintain a safe and comfortable environment for one (1) of one (1) automatic door reviewed (Main Entrance). Specifically, the exterior and interior accessibility (handicap) automatic door opening pads at the main entrance were not functional, requiring residents who used wheelchairs to rely on others for entry and exit from the building.The findings include:The facility policy Maintenance and Service of Medical Equipment and Service Contract Agreements last reviewed March 2024 included completion of a work order in the event of malfunctioning equipment.Resident #9 had diagnoses including polyneuropathy (damage to peripheral nerves) and osteoarthritis (degenerative joint disease). The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and used a wheelchair for mobility, independently self-propelling up to 150 feet with two (2) turns. Review of the current Comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility did not ensure allegations of neglect were thoroughly investigated and documented for one (1) of two (2) residents reviewed (Resident #9). Specifically, Resident #9 sustained an injury when [NAME] Elevator #5 closed on the resident's arm, and the facility did not complete an incident report, initiate an investigation, or conduct a root cause analysis following the incident.The findings include:The facility policy Accident Investigation and Analysis last reviewed December 2025 included all accidents and incidents would be investigated by the department director. Serious accidents, or any unusual frequency of accidents shall be investigated by the Safety Committee.The facility policy Equipment - Incident Investigation last reviewed October 2024 included preparing a report of findings when equipment has been involved in an injury to a patient. If it is suspected an incident was caused by equipment malfunction or caused entirely by improper use of equipment, an incident report form needed to be prepared and submitted.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for two (2) of five (5) residents reviewed (Resident #9 and Resident #12). Specifically, Resident #9's arm was caught in [NAME] Elevator #5 when attempting to stop the elevator door from closing, and Resident #12 was observed using their arm to prevent the elevator door from closing on their wheelchair. The elevator remained operational and accessible to residents, and the facility did not investigate, test, repair, or remove the elevator from service following the incident involving Resident #9.The findings include:The facility policy Accident Investigation and Analysis last reviewed December 2025 included all accidents and incidents would be investigated by the department director. Serious accidents, or any unusual frequency of accidents shall be investigated by the Safety Committee.The facility policy Equipment - Incident Investigation last reviewed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review conducted during the Recertification Survey from 7/22/24-7/26/24, for 7 (Residents #27, #35, #36, #38, #58, #66, #76) of 14 residents reviewed, the facility did not ensure the baseline care plan (developed within 48 hours of admission and included minimum healthcare information necessary to properly care for the immediate needs of the residents, that they were able to understand) was completed within 48 hours of a resident's admission and that a summary of the baseline care plan was provided to the resident and/or their representative. Specifically, for Resident #36, #38, #58, #76, the facility could not provide documented evidence that a baseline care plan was completed within 48 hours of the resident's admission. For Residents #27, #66, and #73, the facility could not provide evidence that a summary of the baseline care plan was provided to the resident and/or their representative. The findings include, but was not limited to, the following: Review of the facility policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interview conducted during the Recertification Survey from 7/22/24-7/26/24, 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 detection in a building that has fuel-burning appliances. The findings are: Observations on 7/23/24 at 10:40 AM included a carbon monoxide detector located on the wall in the Energy Center that housed the 500-Kilowatt (kW) generator. During an interview on 7/24/24 at 2:35 PM, the Facilities Manager asked the surveyor how often the facility is supposed to test the carbon monoxide detectors. When the surveyor responded that they need to be inspected/tested monthly, the Facilities Manager stated that they are probably not doing that monthly. There was no additional documentation provided by the facility of the locations of all carbon monoxide detectors within the facility, nor was their documentation of monthly inspections and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record reviews, conducted during the Recertification Survey, completed on 4/1/22, it was determined that for one of one main kitchen, the facility failed to store, prepare, distribute and serve food in accordance with professional standards (U.S. Food and Drug Administration's Food Code) for food service safety. Specifically, there were multiple undated and unlabeled food items and non-food contact surfaces within the kitchen were not maintained in clean and sanitary condition. This is evidenced by the following: The facility policy, 'Food Storage', reviewed/revised June 2021, included that all products are to be labeled and dated with the receiving date. The policy included that old supplies should be moved to the front of the shelf to ensure rotation of products and new supplies should be placed to the rear of the shelf. The policy included that storerooms, refrigeration units and freezers should be mopped and swept as scheduled and as needed. The facility policy, 'Cleaning and Sanitizing of Work Surfaces', reviewed/revised June 2021, included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (one Housekeeping employee and one Certified Nurse Assistant) of eight employees records reviewed, the facility did not properly implement policies and procedures to prevent abuse. Specifically, the facility did not conduct a Nurse Aide Registry Check prior to hiring employees. This is evidenced by the following: A review of the facility records on 1/23/20 from 2:05 p.m. to 2:55 p.m. revealed one Housekeeping employee began work at the facility on 9/16/19 with no proof of Nurse Aide Registry verification prior to their start date. Further record review of the employee's time detail report revealed the employee worked the following dates: 9/16/19, 9/17/19, 9/19/19, 9/20/19, 9/23/19, 9/24/19, 9/25/19, 9/27/19, 9/28/19, and 9/29/19. Additionally, a timestamp of 1.25 hours was also recorded in the time detail report on 10/4/19. During an interview on 1/23/19 at 2:25 p.m., the Human Resources Manager stated she was unable to locate the Nurse Aide Registry verification for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that that for one of one main kitchen, the facility did not prepare, distribute, and store food under sanitary conditions. The issues involved grilled ham and cheese sandwiches that were not hot held at the proper temperature for food service, improper freezer and dry storage, and the use of metal scouring pads. This is evidenced by the following: The facility's policy, HACCP and Food Handling Principles, dated February 2010, included that hot foods are to be served at between 140 degrees Fahrenheit (*F) to 155*F. The facility's policy, Cleaning and Sanitizing of Work Surfaces, dated July 2018, revealed that a nylon-scouring pad is used as an abrasive to remove food soil from surfaces. Steel wool and metal scouring pads are not permitted. The initial tour of the kitchen on 1/21/20 at 10:30 a.m. and a subsequent tour on 1/23/20 at 11:30 a.m. revealed the following: a. A steel wool, metal scouring…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of three residents reviewed for resident right's, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries to notify them of their appeal rights under the regulation. Specifically, Resident #44 did not receive a Skilled Nursing Facility Advanced Beneficiary Notice or a denial letter at the termination of Medicare Part A benefits. This is evidenced by the following: Resident #44 was admitted to the facility on [DATE] and was discontinued from Medicare Part A services on 12/6/19 and remained in the facility. There was no evidence that a Skilled Nursing Facility Advanced Beneficiary Notice or denial letter was given to the resident or legal representative informing them of their potential liability for payment. When interviewed on 1/23/20 at 11:30 a.m., the Licensed Practical Nurse responsible for billing said she was new to the position, and had just started…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of three residents reviewed for non-pressure related skin conditions, the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs. Specifically, Resident #17 had documented combative behaviors, was at a high risk for skin impairment, and did not have a care plan developed to address behaviors or skin impairment, and Resident #61 had a history of bruising with newly identified bruises on 1/23/20 and there was no care plan in place to address the resident's risk for skin impairment. This is evidenced by the following: 1. Resident #17 had diagnoses including dementia, agitated depression, and osteoarthritis. The Minimum Data Set (MDS) Assessment, dated 11/11/19, revealed the resident had severely impaired cognition. Review of Injury of Unknown Origin Investigation Reports revealed that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #55) of one resident reviewed for infections, the facility did not ensure proper infection control procedures were followed. Specifically, a staff member did not remove soiled gloves or wash their hands prior to touching surfaces in the room and handling a stack of clean briefs. This is evidenced by the following: Resident #55 has diagnoses including clostridium difficile (C-diff, a bacterium that causes diarrhea and colitis - an inflammation of the colon), anxiety, and depression. The Minimum Data Set Assessment, dated 12/19/19, revealed the resident was cognitively intact. The Active Care Plan, dated 1/13/20, revealed that the resident was positive for c-diff, was on contact precautions, and required the assistance of staff with personal hygiene after episodes of loose stools. A progress note, dated 1/13/20, revealed the resident was on an antibiotic (Vancomycin) three times a day and was still having liquid mucous stools. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.