Inspection Reports for
St Anns Community
920 Cherry Ridge Boulevard, Webster, NY, 14580
Back to Facility Profile6 Reports
Inspection Report — Sep 10, 2025
Certification/complaint State
Date: Sep 10, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2022 to 2025 with deficiency and enforcement history.
Complaint Details
The state logged 22 complaints about this facility; 8 led to on-site inspections.
Findings
Across 9 inspections, 6 resulted in citations totaling 33 deficiencies, including 18 standard health and 15 Life Safety Code citations. One enforcement action with fines was recorded, and most citations were corrected.
Citations (27)
Standard Health Citation — quality of care: Feeding assistant training and supervision deficiencies noted.
Standard Health Citation — quality of care: Labeling and storage of drugs and biologicals was inadequate.
Standard Health Citation — quality of care: Environment was not safe, clean, comfortable, or homelike.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system deficiencies found.
Life Safety Code Citation — NFPA requirements: Emergency lighting was deficient.
Life Safety Code Citation — NFPA requirements: Fire alarm system testing and maintenance was inadequate.
Standard Health Citation — quality of care: Baseline care plan was deficient.
Standard Health Citation — quality of care: Labeling and storage of drugs and biologicals was inadequate.
Standard Health Citation — quality of care: Quality of care issues identified.
Standard Health Citation — quality of care: Residents were not free of significant medication errors.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system deficiencies found.
Life Safety Code Citation — NFPA requirements: Fire alarm system testing and maintenance was inadequate.
Life Safety Code Citation — NFPA requirements: Fundamentals of building system categories were deficient.
Life Safety Code Citation — NFPA requirements: Maintenance, inspection, and testing of doors was inadequate.
Life Safety Code Citation — NFPA requirements: Stairways and smokeproof enclosures were deficient.
Standard Health Citation — quality of care: Free from abuse and neglect was not ensured.
Standard Health Citation — quality of care: Reporting to National Health Safety Network was deficient.
Standard Health Citation — quality of care: Reporting to National Health Safety Network was deficient.
Standard Health Citation — quality of care: Care plan timing and revision was deficient.
Standard Health Citation — quality of care: Abuse and neglect policies were not developed or implemented.
Standard Health Citation — quality of care: Facility was not free of accident hazards and lacked proper supervision and devices.
Standard Health Citation — quality of care: Environment was not safe, clean, comfortable, or homelike.
Standard Health Citation — quality of care: Standards of construction for new nursing home were deficient.
Life Safety Code Citation — NFPA requirements: Corridor doors were deficient.
Life Safety Code Citation — NFPA requirements: Electrical systems essential electric system deficiencies found.
Life Safety Code Citation — NFPA requirements: Elevators were deficient.
Life Safety Code Citation — NFPA requirements: HVAC systems were deficient.
Report Facts
Inspections on page: 9
Total violations/deficiencies cited: 33
Inspections with violations: 6
Inspections without violations: 3
Complaints total: 22
On-site complaint inspections: 8
Citations from complaints: 2
Enforcement actions: 1
Total fines: 10000
Inspection Report — Sep 10, 2025
Annual Inspection CMS
Date: Sep 10, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 09/04/2025 to 09/10/2025 to assess compliance with state and federal regulations for nursing home operations.
Findings
The facility was found to have deficiencies related to improper medication storage and administration practices, including pre-pouring medications and documenting them as given before administration. Additionally, the facility failed to ensure feeding assistants had completed required state-approved training and were properly supervised when assisting residents with feeding.
Citations (2)
F 0761: The facility did not ensure all drugs and biologicals were properly stored; six unlabeled medication cups contained pre-poured pills documented as given before administration.
F 0811: The facility did not ensure feeding assistants completed state-approved training and provided feeding assistance only to residents without complicated feeding problems; one resident with dysphagia was fed by an untrained staff member not under licensed nurse supervision.
Report Facts
Medication cups with unlabeled pre-poured pills: 6
Residents with medications pre-poured: 5
Staff trained as paid feeding assistants: 3
Residents eligible for feeding assistance: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Named in medication administration finding regarding pre-pouring medications |
| Director of Nursing | Director of Nursing | Provided statements about proper medication administration procedures |
| Administrative Assistant #1 | Administrative Assistant | Observed feeding resident without required training and named in feeding assistant training deficiency |
| Administrator | Administrator | Provided statements about feeding assistant training requirements |
Inspection Report — May 8, 2024
Complaint Investigation CMS
Date: May 8, 2024
Visit Reason
The inspection was conducted as a Recertification Survey combined with a complaint investigation regarding medication errors at the facility.
Complaint Details
The complaint investigation (#NY00327781) substantiated that Resident #271 received an incorrect medication dose due to a transcription error of a telephone order. The error was identified during preparation for a regulatory visit and was reported to the New York State Department of Health. Corrective actions included medication discontinuation, staff education, and policy review.
Findings
The facility failed to ensure that Resident #271 was free from significant medication errors, resulting in the resident receiving an incorrect dose of pramipexole for Parkinson's disease that exceeded the recommended maximum daily dose for an extended period. The error was due to a transcription mistake of a telephone order and delayed electronic signature, leading to increased hallucinations and a fall for the resident.
Citations (1)
F 0760: The facility did not ensure Resident #271 was free from significant medication errors. The resident received 9 milligrams daily of pramipexole instead of the recommended 3 milligrams daily for over a month due to an incorrectly transcribed telephone order.
Report Facts
Days medication incorrectly administered: 36
Residents reviewed for unnecessary medications: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician Assistant #1 | Gave telephone order that was incorrectly transcribed; approved medication change. | |
| Senior Licensed Practical Nurse #1 | Received telephone order and transcribed it incorrectly, leading to medication error. | |
| Physician #1 | Signed the electronic order late and documented the medication error during regulatory visit preparation. | |
| Pharmacist #1 | Completed medication review and missed the overdose due to alert fatigue. | |
| Director of Nursing | Documented the medication incident and led root cause analysis. |
Inspection Report — May 8, 2024
Annual Inspection CMS
Date: May 8, 2024
Visit Reason
The visit was a Recertification Survey conducted to assess compliance with regulatory requirements for St. Ann's Community nursing home.
Findings
The survey identified multiple deficiencies including failure to provide timely baseline care plans to newly admitted residents, inadequate bowel management for a resident with constipation, a significant medication error involving an incorrect dosage of Parkinson's medication, and unsecured controlled medications in the medication room.
Citations (4)
F 0655: The facility did not provide newly admitted residents or their representatives with a written summary of a Baseline Care Plan including admission orders, dietary, therapy, and social services within 48 hours of admission for 9 of 11 residents reviewed.
F 0684: The facility failed to provide appropriate treatment and care for Resident #2's constipation, with extended periods without documented bowel movements and no comprehensive care plan addressing bowel management.
F 0760: Resident #271 received an incorrect dose of pramipexole for Parkinson's disease, exceeding the recommended maximum daily dose for an extended period due to a transcription error.
F 0761: Controlled medications including narcotics and opioids were observed unsecured and not stored in a double locked cabinet in the third-floor medication room.
Report Facts
Residents reviewed for baseline care plan: 11
Consecutive shifts without bowel movement: 16
Consecutive shifts without bowel movement: 11
Consecutive shifts without bowel movement: 13
Incorrect medication dose: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Senior Licensed Practical Nurse #1 | Senior Licensed Practical Nurse | Named in medication error finding for transcription of incorrect medication dose |
| Physician Assistant #1 | Physician Assistant | Named in medication error finding for providing telephone order |
| Director of Nursing | Director of Nursing | Interviewed regarding baseline care plan provision, bowel management, medication error, and medication storage |
| Registered Nurse Manager #1 | Registered Nurse Manager | Interviewed regarding bowel management and medication storage |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding bowel management and medication storage |
Inspection Report — Sep 13, 2023
Complaint Investigation CMS
Date: Sep 13, 2023
Visit Reason
The inspection was conducted as an abbreviated survey triggered by a complaint (Complaint #NY00323662) regarding alleged abuse of a resident by a staff member.
Complaint Details
The complaint investigation was substantiated based on video evidence and interviews. The CNA involved was terminated. Resident #1 showed no physical or psychological distress following the incident according to medical and social work notes.
Findings
The facility was found to have failed to ensure a resident was free from verbal, mental, and physical abuse by a staff member. Video evidence showed a Certified Nursing Assistant (CNA) being rough, slapping, yelling at, and intimidating the resident. The CNA was terminated following the incident.
Citations (1)
F 0600: The facility did not protect Resident #1 from verbal, mental, and physical abuse by a staff member who slapped the resident, yelled at them, and pointed a finger in an intimidating manner.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Named in abuse finding and terminated following the incident. | |
| Director of Nursing (DON) | Conducted facility investigation and provided interview statements. | |
| Social Worker #1 | Documented resident's psychological status post-incident. | |
| Administrator | Interviewed regarding family-installed camera and incident. |
Inspection Report — Aug 29, 2022
Annual Inspection CMS
Date: Aug 29, 2022
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with regulatory requirements for the nursing home facility.
Findings
The facility was found to have multiple deficiencies including unsafe and poorly maintained wheelchairs, incomplete employee abuse screening policies, failure to update resident care plans to reflect current needs, and unsafe storage of hazardous chemicals accessible to residents.
Citations (4)
F 0584: The facility did not provide a safe, clean, comfortable, and homelike environment as three residents were observed using wheelchairs with cracks, peeling material, and exposed foam padding.
F 0607: The facility failed to implement written policies and procedures to prevent abuse, neglect, and exploitation by not completing nurse aide registry abuse screenings prior to new employees beginning work.
F 0657: The facility did not review and revise residents' care plans to reflect current needs, including failure to update care plans for contracture management and pressure ulcer treatment.
F 0689: The facility did not ensure the environment was free from accident hazards as hazardous chemicals were stored in unlocked rooms accessible to residents, including those with dementia and wandering behaviors.
Report Facts
Residents affected: 3
Employees reviewed: 5
Employees with deficient screening: 2
Resident care units: 6
Residents affected: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Stated environmental services clean wheelchairs every three months and maintenance fixes wheelchairs | |
| Licensed Practical Nurse (LPN) #2 | Observed wheelchair condition and stated Resident Care Coordinator is notified of equipment issues | |
| Director of Nursing (DON) | Provided information on wheelchair maintenance and care plan responsibilities | |
| Facility Manager | Stated wheelchair condition checks occur only upon notification, no audits performed | |
| Human Resources (HR) Manager | Discussed deficiencies in nurse aide registry abuse screening policies | |
| Certified Nursing Assistant (CNA) | Reported use of powdered gauze for Resident #40's hands | |
| Social Worker | Stated some residents do their own laundry without supervision |
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