St. Ann's Community

Based on observations, interviews, and record review conducted during a Recertification Survey from 09/04/2025 to 09/10/2025, for one (1) (3200 Unit) of two (2) medication carts reviewed, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal laws. Specifically, there were multiple pre-poured pills in six (6) unlabeled medication cups and all the pre-poured medications were signed off as given in the Medication Administration Record prior to administering them to the residents. The findings include:The facility policy Medication-Preparation and Administration, dated 06/02/2022, included medications may not be set up in advance, medications must be administered within one (1) hour before or after their prescribed time, and to document after medications are taken by the resident.During an observation and interview on 09/09/2025 at 9:10 AM, a medication cart (3200 Unit) had six (6) unlabeled medication cups with various pills in each cup. During an interview at that time, Licensed Practical Nurse #2 stated the cups contained…

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 conducted during a Recertification Survey from 09/04/2025 to 09/10/2025, for one (1) (Resident #34) of one (1) resident reviewed, the facility did not ensure feeding assistants had successfully completed a State-approved training course that meets the requirements before feeding residents and feeding assistants provided dining assistance only for residents who have no complicated feeding problems. Specifically, Resident #34 who had a diagnosis of dysphagia (difficulty swallowing food or liquids) was observed receiving assistance with their breakfast meal from a staff member who had not completed an approved paid feeding assistant training program. Additionally, Resident #34's care plan did not reflect the use of a feeding assistant and the staff member was not under the direct supervision of a licensed nurse. The findings include:An official communication issued by the New York State Department Health, Dear Administrator Letter #07-11 (Paid Feeding Assistants), dated 12/20/2007, included nursing homes are allowed to utilize…

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 a Recertification Survey, the facility did not ensure that newly admitted resident's and/or their representatives were provided with a written summary of a Baseline Care Plan that included the minimum healthcare information necessary to properly care for the immediate needs of the resident (including but not limited to initial goals, admission orders, dietary, therapy and social services) for 9 (Residents #2, #7, #31, #40, #53, #55, #56, #57 and #58) of 11 residents reviewed. Specifically for all residents identified the facility did not provide the resident or their representative with a summary of a Baseline Care Plan in a timely manner. This is evidenced by, but not limited to the following: The current facility policy, Care Planning-Interdisciplinary, dated 7/12/22, included a baseline care plan is initiated and completed with 48 hours of admission and developed before the comprehensive assessment. Prior to the scheduled care plan meeting a copy of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the Recertification Survey, for one (Residents #2) of one resident reviewed the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, Resident #2 had several extended periods of time without a documented bowel movement, did not receive appropriate interventions to manage their bowel patterns, and did not have a comprehensive care plan in place to address a diagnosis of constipation. This is evidenced by the following: The facility policy and procedure, Bowel Management, date 1/28/19 included that Nursing would monitor the bowel regimen where appropriate and establish a care plan to ensure the Elder (Resident) was having regular bowel patterns. The electronic documentation system bowel management report would be reviewed daily. If an Elder had no bowel movement after more than six shifts, the staff nurse should initiate the as needed bowel regimen as ordered or notify…

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 and complaint investigation (#NY00327781), it was determined that for one (Resident #271) of six residents reviewed for unnecessary medications, the facility did not ensure that the resident was free from significant medication errors. Specifically, Resident #271 received an incorrect dose of a medication for Parkinson's disease for an extended period of time, in a dose that exceeded the recommended maximum daily dose and not as recommeded by the specialist. This is evidenced by the following: The facility policy and procedure, Internal and External Consults and Clinics, revised 7/25/22, included that any orders, reports, or notes received from an outside clinician upon return of the resident are given to nursing for review. The nursing team will read the note/recommendations and/or email the note/reconditions to the provider for review. The orders, notes, and reports are scanned into the medical record after being dated 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 review conducted during a Recertification Survey, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws for one (third-floor resident unit) of two medication rooms reviewed. Specifically, numerous controlled medications (drugs that are regulated by law due to their potential for abuse or addiction), including narcotics and opioids were observed unsecured and not in a double locked cabinet per the regulations. This is evidenced by the following. The facility policy Medications-Storage, Distributions, Administration and Wasting of Controlled Substances, dated 4/11/22 documented that controlled substances must be stored, distributed, and administered in a safe, secure manner with total compliance with all legal and regulatory requirements. The narcotics supply is to be kept under two locks at all times, and all controlled substances are to be returned to the medication room narcotic cabinet and double-locked after a medication pass. During an observation and interviews on…

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 conducted during an Abbreviated Survey (Complaint # NY00323662) it was determined for one (Resident #1) of three residents reviewed for abuse the facility did not ensure the resident was free from the use of verbal, mental, or physical abuse. Specifically, Resident #1 was slapped on the abdomen, yelled at, and observed having a finger pointed in their face in an intimidating manner by a staff member. This is evidenced by the following: The facility policy, Elder Abuse/Neglect/Mistreatment Policy, dated 7/22/23, defined abuse as inappropriate physical contact with an Elder of a residential health care facility, while the Elder is under the supervision of the facility, which harms or is likely to harm the Elder. Inappropriate physical contact includes, but is not limited to, striking the Elder. Additionally, verbal abuse could include a threat or physical action such as a threatening gesture or intimidation. Resident #1 had diagnoses including dementia with…

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 conducted during the Recertification Survey completed on 8/29/22, it was determined that for two (Employees #2 and #4) of five employee files reviewed, the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, a nurse aide registry (NAR) abuse screening was not completed prior to new employees beginning work. The findings are: On 8/26/22 from 10:30 a.m. to 11:55 a.m., documentation related to five recently hired employees was reviewed. The records included that employee #2 was hired as a Beauty Technician on 6/28/22. The documentation provided included a nurse aide registry abuse screening for employee #2 dated 3/8/21. Additionally, employee #4 was hired on 6/6/22 as a Care Partner and the NAR screening was dated 8/24/22. During an interview at this time, the Human Resources (HR) Manager stated that a NAR screening wasn't done originally for employee #4, and was done when the surveyors came in. During…

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 and interviews conducted during the Recertification Survey completed on 8/29/22, it was determined that the facility did not ensure that the environment remained as free of accident hazards as possible. Specifically, on six of six resident care units, hazardous chemicals were stored in unlocked rooms and accessible to 57 residents including many with dementia and/or wandering behaviors. This is evidenced by the following: Review of facility policy Storage and handling of toxic and potentially hazardous chemicals, medications and treatment procedures, dated 12/22/94 included that the policy statement was to insure the protection and safety of elders/patients, all toxic and potentially hazardous chemical, medications, and treatment products will be store in designated locked areas when not in direct use. Section A: Cleaning Supplies #3: Return the cleaning supplies to a locked cupboard, at no time are cleaning supplies to be left out where they could be assessable to elders/patients. Section B: Treatment Items #1: Obtain treatment item from locked treatment cart,…

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, conducted during the Recertification Survey, completed on 8/29/22, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment for three of three residents reviewed. Specifically, Residents #3, #7, and #63 were observed on multiple days occupying wheelchairs with cracks, peeling material, and exposed padding. This is evidenced by: 1.Resident #7 had diagnoses including arthritis, osteoporosis, anxiety, and depression. The Minimum Data Set Assessment (MDS), dated [DATE], documented that Resident #7 was cognitively intact and required the use of a wheelchair. The resident also required extensive assistance from staff for transfers. During and observation and interview on 8/24/22 at 9:22 a.m., Resident #7 was sitting in a wheelchair. The left arm fabric of the wheelchair was peeled off esposing the foam padding. Residnet #7 stated at this time that they had had the wheelchair for a quite awhile. During an observation…

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 conducted during a Recertification Survey, completed on 8/29/22, it was determined that for one (Resident #40) of one resident reviewed for position/mobility and one (Resident # 23) of one resident reviewed for pressure ulcers, the facility did not review and revise the resident's care plan (with input from the resident or resident representative to the extent possible) to reflect the resident's current needs. Specifically, Resident #40's Comprehensive Care Plan (CCP) was not revised to reflect the discontinued use of hand splints and washcloths for hand contractures and Resident #23's CCP did not reflect the history of and current presence and treatment of existing pressure ulcer. This was evidenced by the following: The facility policy, Care Planning-Interdisciplinary, revised 7/12/22, included that the Care Plan was reviewed and updated with any change in status (minimally, quarterly). 1.Resident #40 had diagnoses including dementia, contractures of left and right hand, and anxiety. The Minimum Data Set Assessment, dated…

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.