St Josephs Home

Based on observations, record review, and interviews, the facility failed to ensure residents were treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of quality of life, recognizing each resident's individuality during meal service in two (2) of two (2) dining rooms (First and Second floor dining rooms). Specifically, residents stated they were not allowed to visit residents at other tables and/or visitors were not allowed to visit in the dining rooms during and after mealtimes. Findings include: The facility policy Resident's Rights Policy, reviewed 11/2025, documented the residents were provided a homelike environment which fully provides their right to a dignified existence. The residents had a right to a homelike environment and to incorporate personal and cultural preferences within their goals of care. Residents have the right to immediate and unlimited access by friends and family. Residents had the right to interact with members of the community both inside and outside the facility and the right to make choices about…

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 record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice for one (1) of three (3) residents (Resident #3) reviewed. Specifically, Resident #3 had diabetes and was responsible for reading their own blood sugar results with a blood glucose sensor device (a small sensor-based system applied to the back of the arm that provides continuous glucose readings without finger sticks). The resident's twice a day weekly blood glucose finger sticks was discontinued without a medical order and their blood glucose levels and sliding scale insulin were not documented as completed two (2) times in March 2026. Findings include:The facility policy Blood Glucose Monitoring, last reviewed 12/2025, documented residents with diabetes mellitus would have their blood glucose monitored by a registered nurse or licensed practical nurse as ordered by the physician and by nursing judgement. The blood glucose would be recorded with 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 observation, record review, and interviews the facility failed to ensure that residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #12) reviewed. Specifically, Resident #12 received hemodialysis treatments at a community-based dialysis center, and the facility did not have a plan to adequately monitor and care for the resident pre and post dialysis. Findings include:There was no documented evidence of a dialysis policy.Resident #12 had diagnoses including chronic kidney disease and dependence on dialysis. The 12/13/2025 Minimum Data Set assessment documented the resident was cognitively intact, had end stage kidney disease, and was dependent on dialysis treatments.The Comprehensive Care Plan reviewed and revised on 03/15/2026 documented the resident had kidney failure and received hemodialysis on Monday, Wednesday, and Friday at the dialysis center. The care plan did not include any specific care instruction,…

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, record review, and interviews, the facility failed to ensure a resident was provided medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for one (1) of one (1) resident (Resident #6) reviewed. Specifically, Resident #6 had a history of depression with episodes of night terrors and did not have a person-centered care plan to address the resident's depression and did not have social work follow up to address the resident's history of post-traumatic stress disorder or psychosocial concerns.Findings include:The facility policy Resident's Rights Policy, last reviewed 11/2025 documented the facility would ensure the residents are provided with a home like environment which fully provides their right to a dignified existence including full recognition of their individuality and privacy and to participate in their care possible. The resident has the right to make choices about all aspects of their life. The facility will meet the residents' individual needs and preference to 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 observation, record review, and interview during the recertification survey conducted 3/25/2024-3/29/2024, the facility did not review the risks and benefits of enabler rails or obtain informed consent prior to the installation of enabler rails with the resident or resident representative for 10 of 10 residents (Residents #2, #4, #81, #41, #60, #71, #59, #23, #80, and #62) reviewed. Specifically, there was no documented evidence the risks and benefits of enabler rails were explained to the residents, or their representatives or consents were obtained prior to bed rail use for Residents #2, #4, #81, #41, #60, #71, #59, #23, #80, and #62 Findings include: The facility policy Physical Restraints last reviewed 9/2023, documented the facility is committed to reducing the use of unnecessary physical restraints and ensuring residents are free of physical restraint unless permitted by federal regulation. Physical Restraint included any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot remove…

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 observation, record review, and interview during the recertification survey conducted 3/25/2024-3/29/2024, the facility did not ensure storage, preparation, distribution, and service of food in accordance with professional standards for food service safety in 1 of 1 main kitchen. Specifically, the main kitchen had undated and uncovered food, the food slicer and can opener had food debris on them, and ceiling tiles and walls were not clean. Findings include: The facility policy Kitchen Cleaning Standards revised 5/2023 documented cleaning of the kitchen is a difficult task as many things need to occur to prepare meals, meet resident needs, and assure appropriate food temperatures. Cleaning the kitchen is everyone's responsibility. Many areas of the kitchen are high and difficult to reach and may need maintenance to assist. If areas require cleaning, put in a maintenance request. Many areas are subject to spray and soiling, every effort should be made to clean these areas when needed. Any concerns regarding cleaning needs should be communicated to the cook, who can get staff…

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 observation, record review, and interview during the recertification and abbreviated (NY00297353) surveys conducted 3/25/2024-3/29/2024, the facility did not implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 3 residents (Resident #23) reviewed. Specifically, recreation aide #8 witnessed an alleged abuse incident by certified nurse aide #7 towards Resident #23 and did not intervene to stop the interaction and did not immediately report the alleged abuse to Administration per the facility policy. Additionally, certified nurse aide #7 completed their shift after the alleged abuse incident occurred. Findings include: The facility policy Resident abuse, neglect, mistreatment and misappropriation of resident property revised 1/2024 documented the facility encouraged and supported all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion, or misappropriation. Abuse was defined as the willful infliction of…

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 observation, record review, and interview during the recertification survey conducted 3/25/2024-3/29/2024, the facility did not ensure residents were free of any significant medication errors for 1 of 9 residents (Resident #14) reviewed. Specifically, Resident #14's prepared medications were left in a cup unattended on their bedside table for over 5 hours and licensed practical nurse #3 documented the medications were administered at 6:00 AM when they were not. Findings include: The facility policy Medication Policies Program reviewed 9/2023 documented medications were administered by a licensed nurse. The person that administered the medication ensured the six rights (right person, medication, dose, route, time, and documentation). Resident medication was accurately acquired, received, dispensed, administered, and documented in a safe and efficient manner. The facility policy Self-Administration Policy reviewed 9/2023 documented residents had the right to self-administer medications. Standards had to…

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 observation, interview, and record review during the recertification survey conducted 12/7/21-12/10/21, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one isolated area (kitchen exhaust hood area) in the main kitchen. Specifically, the kitchen exhaust hood and Ansul lines (special hazard fire protection products) over the oven and stoves were grease and dust laden. Findings include: The semi-annual hood cleaning logs documented the kitchen hoods were last cleaned on 9/9/21 and 5/11/21. When observed on 12/7/21 at 10:18 AM, the ventilation filters under the kitchen exhaust hoods over the cooking appliances (stove, fryer, and ovens) contained grease and were dust laden in sections. The Ansul suppression lines were observed with grease and were dust laden. When interviewed on 12/8/21 at 11:40 AM, the Food Service Manager stated maintenance should be cleaning hoods semi-annually by taking the vents outside to power wash and degrease them. The Manager stated 9/2021 was the last time the hood…

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 observation, interview, and record review during the recertification survey conducted from 12/7/21-12/10/21 the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 2 of 2 nursing units (Units 1 and 2) reviewed. Specifically, the facility policy Food Brought in From Home did not document how long food items could be kept before discarding, how to safely reheat and serve residents' personal food including how to properly take food temperatures and what appropriate reheating temperatures were. Finding include: The facility policy Food Brought in From Home dated 7/12/21, did not document how to safely reheat food for residents, how to take temperatures of the food, what temperature foods must be reheated to, or how long residents' food brought in from outside the facility should be kept before being discarded. During an observation on 12/7/21 at 11:47 AM, the Unit 2 nourishment refrigerator had 3 resident food items that were properly labeled.…

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.