St. John's Health Care Corporation

In the surveyor’s words

From the most serious findings on record at St. John's Health Care Corporation, in the surveyor’s own words.

• Actual harm, isolatedF677Jun 9, 2025

  Based on observations, interviews, and record review conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for three (3) (Residents #120, #213 and #222) of seven (7) residents reviewed. Specifically, Resident #120 was observed with debris underneath multiple fingernails and eating food items with their hands. Resident #213 was observed over several days with greasy hair and the facility was unable to provide evidence of the resident getting their hair washed for the prior month. […]

• Actual harm, isolatedF690Jun 9, 2025

  Based on observations, interviews and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility failed to ensure residents with indwelling urinary catheters (a tube inserted into the bladder to drain urine) received the care and services to manage the urinary catheter for two (2) (Resident #112 and #222) of four (4) residents reviewed. Specifically, Resident #112 had a urinary catheter that was not consistently secured to prevent tension resulting in a genital injury. Additionally, Resident #112's Comprehensive Care Plan did not include the presence of a urinary catheter or interventions for appropriate care of the urinary catheter to prevent complications. […]

• Actual harm, isolatedF686Dec 13, 2023

  Based on observations, interviews and record review conducted during the Recertification Survey and complaint investigation (#NY00300345) from 12/6/23 to 12/13/23, for three (Residents #90, #108 and #183,) of six residents reviewed for pressure ulcers, the facility failed to ensure the residents received the necessary care, treatment, and services, consistent with professional standards of practice, to promote healing, prevent new pressure ulcers from developing, and/or prevent existing pressure ulcers from worsening. Specifically, the facility did not consistently provide Residents #90, #108 and #183 with physician-ordered treatments for skin impairments and/or care plan interventions. This resulted in actual harm to Resident #90 that is not Immediate Jeopardy. […]

• No harm, potential for more than minimal, patternF554Jun 9, 2025

  Based on observations, interviews, and record review conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, for one (1) (Resident #28) of one (1) resident reviewed, the facility did not ensure the interdisciplinary team determined the resident's right to self-administer medications was clinically appropriate. Specifically, there were multiple observations of unsecured medications left at Resident #28's bedside and the resident had not been assessed for their ability to self-administer medications. Additionally, there was no medical order or comprehensive care plan in place to address the self-administration of medications. […]

• No harm, potential for more than minimal, patternF609Jun 9, 2025

  Based on interviews and record review conducted during the Recertification Survey and complaint investigations (NY00352162 and NY00356860) from 06/02/2025 to 06/09/2025 for 6 (Residents #23, #27, #93, #210, #313, #721) of 14 residents reviewed, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported to the New York State Department of Health in accordance with state law. Specifically, Resident #23 and #721 both had multiple unwitnessed falls including one with a major injury. Resident #27 had multiple bruises on their face of unknown origin. Resident #210 was observed by staff engaging in potential sexual abuse towards Resident #93. […]