St Johnsville Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at St Johnsville Rehabilitation and Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF550Sep 3, 2025

  Based on observations, record review and interviews conducted during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life for two (2) (Resident #s 11 and 86) of 24 residents reviewed. Specifically, (a.) Resident #11 foley's catheter bag was exposed; (b.) Resident #86 heard Certified Nurse Aide #1 and Certified Nurse Aide #2 stated they had to wait and be the last one for care because they were so slow. Certified Nurse Aide #2 when asked to remove a raised toilet seat before Resident #86 used the bathroom, they replied, 'no, I am not breaking my back.' Resident #86 stated in both instances they were offended. […]

• No harm, potential for more than minimal, patternF692Sep 3, 2025

  Based on record review and staff interviews conducted during the recertification survey, the facility did not ensure that it maintained acceptable parameters of nutritional status, provided nutrition care and services to each resident consistent with the resident's comprehensive assessment for three (3) (Resident #s 6, 48, and 107) of seven (7) residents reviewed for nutrition/hydration status maintenance. Specifically, (a.) Resident #6 had a documented weight loss of 17.7 pounds in a month, (b) Resident #48 had a documented weight gain of 22.5 pounds in a month, and (c) Resident #107 had a documented weight loss of 35.6 pounds. […]

• No harm, potential for more than minimal, patternF725Sep 3, 2025

  Based on observation, record review, and interviews conducted during a recertification and abbreviated survey (Case # 2562681), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, residents reported that staff would not be able to provide them care for extended periods of time. Review of the actual staffing schedule revealed that on multiple occasions from 08/11/2025 to 09/01/2025, the facility staffing levels were below the facility assessment. This is evidenced by: The Facility Assessment, last reviewed in July 2025, documented that the facility's bed capacity was 120. […]

• No harm, potential for more than minimal, patternF732Sep 3, 2025

  Based on observations and interview conducted during the recertification survey, it was determined that the facility did not post nurse staffing information in an area accessible to all residents and visitors, as required by the posting requirements. Specifically, the posting of daily nurse staffing levels for staff working in the facility on each shift from 08/25/2025 through 09/03/2025 was located at the far end of the building. This is evidenced by: During observations from 8/25/2025 through 9/03/2025, the daily nurse staffing postings were located in a hallway at the far end of the building near the human resources office, which was not readily visible or accessible to all residents and visitors. […]

• No harm, potential for more than minimal, patternF759Sep 3, 2025

  Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed five (5) percent for two (2) (Resident #s and 46) of two (2) residents observed during medication administration with 25 observations. This resulted in a medication error rate of 88 percent.This is evidenced by:The facility ' s Policy and Procedure titled, Medication Nurse Routine. Revised: 12/19/2024, documented all Medication Nurse duties are performed by licensed personnel. Procedures will be performed as follows by all staff uniformly. During the medication pass read orders from electronic medical record, Compare prescription label on blister pack to medication order. […]