Inspection Reports for
St Johnland Nursing Center, Inc
395 Sunken Meadow Road, Kings Park, NY, 11754
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
124% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 10, 2025
Visit Reason
Immediate jeopardy level 4 deficiency for free from abuse and neglect with pattern scope and substandard quality of care, corrected as of April 17, 2025.
Findings
Immediate jeopardy level 4 deficiency for free from abuse and neglect with pattern scope and substandard quality of care, corrected as of April 17, 2025.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 10, 2025
Visit Reason
The abbreviated survey was conducted to investigate allegations of sexual abuse and inadequate supervision of residents at the facility.
Findings
The facility failed to ensure residents were free from sexual abuse, resulting in immediate jeopardy to resident health and safety. Multiple incidents involving Resident #1 sexually touching other residents were documented and confirmed through interviews and investigations.
Deficiencies (1)
F 0600: The facility did not protect residents from all types of abuse including sexual abuse. Resident #1 was observed touching the genital areas of Residents #2, #3, and #4 on multiple occasions without adequate supervision.
Report Facts
Residents affected: 3
Brief Interview for Mental Status (BIMS) scores: 9
Brief Interview for Mental Status (BIMS) scores: 4
Brief Interview for Mental Status (BIMS) scores: 3
Brief Interview for Mental Status (BIMS) scores: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Responded to call for help and observed Resident #1 touching other residents inappropriately. | |
| Licensed Practical Nurse #3 | Observed Resident #1's inappropriate behavior in the dining room. | |
| Registered Nurse #4 | Responded to Resident #4's room and observed abuse by Resident #1. | |
| Director of Nursing | Interviewed regarding supervision failures and actions taken after incidents. | |
| Certified Nursing Assistant #4 | Reported observations of Resident #1's behavior and staff responses. | |
| Registered Nurse #2 | Provided statements about supervision and observations of Resident #1. | |
| Medical Director | Stated residents should not be touched in a sexually inappropriate manner and facility responsibility. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: Dec 10, 2024
Visit Reason
Multiple level 2 deficiencies related to care plan timing, competent nursing staff, comprehensive care plan, food sanitation, accident hazards, infection control, drug labeling, diet, resident call system, resident rights, and nursing staff sufficiency; life safety code deficiencies for dietary services, elevators, exit signage, and fire drills; all corrected by early 2025.
Findings
Multiple level 2 deficiencies related to care plan timing, competent nursing staff, comprehensive care plan, food sanitation, accident hazards, infection control, drug labeling, diet, resident call system, resident rights, and nursing staff sufficiency; life safety code deficiencies for dietary services, elevators, exit signage, and fire drills; all corrected by early 2025.
Deficiencies (15)
Care plan timing and revision
Competent nursing staff
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Infection prevention & control
Label/store drugs and biologicals
Provided diet meets needs of each resident
Resident call system
Resident rights/exercise of rights
Sufficient nursing staff
Dietary services
Elevators
Exit signage
Fire drills
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Dec 10, 2024
Visit Reason
The inspection was a Recertification Survey conducted to assess compliance with state and federal regulations for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident dignity during meal service, incomplete care planning, inadequate supervision and assistance leading to resident injury, insufficient nursing staffing, improper medication handling, failure to assess and accommodate food preferences, unsafe food temperature control, and call bell accessibility issues.
Deficiencies (11)
F 0550: The facility did not ensure residents were treated with dignity during meal service as some residents at the same table were served late due to delayed meal transport rack delivery.
F 0656: The facility failed to develop and implement a complete care plan for Resident #152, who was observed using a wheelchair without required bilateral leg rests as ordered.
F 0657: The facility did not ensure participation of Resident #66 or their representative in quarterly care plan meetings, which were not held as required.
F 0689: Resident #73 was transferred alone using a mechanical lift requiring two-person assistance, resulting in a head injury and bruising.
F 0725: The facility did not provide sufficient nursing staff on multiple units, resulting in missed showers, delayed care, and inadequate assistance for residents.
F 0726: Certified Nursing Assistant #14 failed to demonstrate competency by transferring Resident #73 alone despite a two-person assistance order, causing resident injury.
F 0761: Medications and biologicals were not properly labeled or stored; two unlabeled tubes of Voltaren cream were found in Resident #19's room without physician orders.
F 0800: Resident #79 was not assessed for food preferences upon admission and did not receive menus; resident verbalized disliking served food.
F 0812: Cold food items (sandwiches, potato salad, pudding) were served at temperatures above safe limits (48-50°F) without temperature monitoring, risking foodborne illness.
F 0880: Registered Nurse #1 handled oral medications with bare hands during administration to Resident #46, violating infection control policies.
F 0919: Resident #39's call bell was observed out of reach multiple times; staff acknowledged call bell should be within reach at all times.
Report Facts
Residents in Head Injury Unit: 15
Residents in Inn Unit: 40
Residents in [NAME] Unit: 50
Residents in [NAME] Hall Unit: 46
Residents in Muhlenberg Unit: 17
Residents in Sub-Acute ([NAME] Hall) Unit: 22
Residents in Sunset Hall Unit: 40
Temperature of cold food items: 48
Temperature of cold food items: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #14 | Transferred Resident #73 alone despite two-person assistance order, causing injury | |
| Registered Nurse #1 | Handled oral medications with bare hands during administration to Resident #46 | |
| Licensed Practical Nurse #2 | Noted transport racks for meals were late causing dignity issues during meal service | |
| Certified Nursing Assistant #1 | Noted Resident #152 wheelchair lacked leg rests and attempted to find replacements | |
| Director of Nursing Services | Acknowledged failures in care planning, staffing, and medication handling | |
| General Manager | Dietary Services | Acknowledged food temperature violations and meal delivery issues |
| Dietician #1 | Stated resident food preferences were not documented initially |
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Dec 10, 2024
Visit Reason
The survey was a recertification and abbreviated survey conducted to assess compliance with nursing home regulations, including resident safety, staffing adequacy, and care competencies.
Findings
The facility failed to ensure adequate supervision and accident prevention for residents requiring two-person assistance, had insufficient nursing staff on multiple units leading to missed care such as showers and delayed transfers, and did not ensure nurse aides demonstrated competency in resident care. Additionally, call bells were not consistently kept within reach of residents.
Deficiencies (4)
F0689: The facility failed to ensure a nursing home area was free from accident hazards and residents received adequate supervision to prevent accidents. Certified Nursing Assistant #14 transferred Resident #73 alone despite two-person assistance being required, resulting in a resident injury.
F0725: The facility did not provide enough nursing staff daily to meet resident needs, resulting in understaffing on multiple units and missed care such as showers and delayed resident transfers.
F0726: The facility failed to ensure nurse aides demonstrated competency in resident care. Certified Nursing Assistant #14 transferred Resident #73 without required two-person assistance despite prior counseling and education.
F0919: The facility did not ensure call bells were within reach for each resident at their bedside. Resident #39 was observed with a call bell out of reach on multiple occasions.
Report Facts
Residents in Head Injury Unit: 15
Residents in Inn Unit: 38
Residents in [NAME] Unit: 50
Residents in [NAME] Hall Unit: 46
Residents in Muhlenberg Unit: 17
Residents in Sub-Acute ([NAME] Hall) Unit: 22
Residents in Sunset Hall Unit: 40
Residents requiring two-person assistance: 13
Residents requiring two-person assistance: 23
Residents requiring assistance with incontinence care: 31
Residents dependent or requiring assistance with eating: 9
Residents assigned per Certified Nurse Assistant: 19
Residents assigned per Certified Nurse Assistant: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #14 | Named in findings for transferring Resident #73 without required two-person assistance, resulting in resident injury and prior counseling for similar incident | |
| Registered Nurse Risk Manager #7 | Registered Nurse Risk Manager | Interviewed staff and confirmed Certified Nursing Assistant #14 did not ask for assistance with lift transfer |
| Director of Nursing Services | Director of Nursing Services | Stated Certified Nursing Assistant #14 did not follow plan of care and mechanical lift transfers require two-person assistance |
| Certified Nurse Assistant #11 | Certified Nurse Assistant | Reported understaffing and inability to provide showers or two-person assistance on Head Injury Rehabilitation Unit |
| Certified Nurse Assistant #3 | Certified Nurse Assistant | Reported understaffing and working alone on [NAME] Hall Unit night shift |
| Staffing Coordinator #1 | Staffing Coordinator | Acknowledged understaffing and facility assessment requirements for nursing staff |
| Assistant Director of Nursing Services #2 | Assistant Director of Nursing Services | Acknowledged staffing shortages and instructed staff to give bed baths when showers cannot be provided |
| Administrator | Administrator | Acknowledged staffing challenges and efforts to recruit new staff |
| Certified Nurse Assistant #3 | Certified Nurse Assistant | Placed call bell on Resident #39's lap and stated call bell should be within reach |
| Chief Nursing Officer | Director of Nursing Services | Stated call bells must be kept within reach of residents |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 2, 2024
Visit Reason
Level 2 deficiency for reporting to national health safety network with widespread scope, not corrected at time of report.
Findings
Level 2 deficiency for reporting to national health safety network with widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
Date: May 18, 2023
Visit Reason
Level 2 and 3 deficiencies related to ADL care, abuse and neglect, accident hazards, infection control, resident records, and services; life safety code deficiencies for electrical systems, illumination, means of egress, and sprinkler system; all corrected by mid-2023.
Findings
Level 2 and 3 deficiencies related to ADL care, abuse and neglect, accident hazards, infection control, resident records, and services; life safety code deficiencies for electrical systems, illumination, means of egress, and sprinkler system; all corrected by mid-2023.
Deficiencies (10)
ADL care provided for dependent residents
Free from abuse and neglect
Free of accident hazards/supervision/devices
Infection prevention & control
Resident records - identifiable information
Services provided meet professional standards
Electrical systems - essential electric syste
Illumination of means of egress
Means of egress - general
Sprinkler system - maintenance and testing
Inspection Report
Annual Inspection
Deficiencies: 6
Date: May 18, 2023
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey to assess compliance with regulatory standards and investigate complaints.
Findings
The facility was found deficient in multiple areas including failure to prevent resident abuse, inadequate monitoring of vital signs for readmitted residents, unsafe transfer practices, failure to provide assistive devices leading to resident injury, incomplete medical record documentation, and lapses in infection prevention and control practices.
Deficiencies (6)
F 0600: The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant who was observed tapping the resident's shoulder aggressively, waving a phone in the resident's face, and causing bruising and a scratch during a medical appointment.
F 0658: The facility did not ensure monitoring of vital signs on the 11:30 PM to 7:30 AM shift for a readmitted resident with head injury and chest contusion, resulting in lack of documented assessments during that shift.
F 0677: The facility failed to provide necessary assistance for transfers, resulting in a resident falling when transferred by a single staff member instead of two as required by the care plan.
F 0689: The facility did not ensure use of wheelchair leg rests during transport, causing a resident's foot to get caught under the wheelchair and resulting in a left femur fracture.
F 0842: The facility failed to maintain complete and accurate medical records as the physician's monthly progress notes did not address a resident's right upper extremity deep vein thrombosis status.
F 0880: The facility failed to implement infection prevention practices when a Licensed Practical Nurse did not perform hand hygiene after cleansing a resident's Stage III pressure ulcer wound and before donning clean gloves.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Named in abuse finding and subsequent termination |
| LPN #2 | Licensed Practical Nurse | Named in failure to document vital signs for readmitted resident |
| CNA #4 | Certified Nursing Assistant | Named in unsafe transfer causing resident fall |
| PT #1 | Physical Therapist | Named in wheelchair accident causing resident fracture |
| LPN #3 | Licensed Practical Nurse | Named in infection control deficiency for improper hand hygiene |
| RN #1 | Registered Nurse | Updated care plan for resident with DVT |
| MD #1 | Physician | Provided orders and interviewed regarding resident injury and DVT |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 18, 2023
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey to assess compliance with regulatory standards and investigate complaints received by the facility.
Findings
The facility was found deficient in protecting residents from abuse, ensuring professional standards of care, providing necessary assistance for activities of daily living, and preventing accidents related to assistive devices. Several residents experienced harm or potential harm due to staff actions or omissions.
Deficiencies (4)
F 0600: The facility failed to protect Resident #142 from physical abuse by a Certified Nursing Assistant who was observed hitting the resident's shoulder and behaving aggressively during a medical appointment.
F 0658: The facility failed to ensure Resident #356 received proper monitoring of vital signs during the 11:30 PM to 7:30 AM shift after readmission, resulting in lack of documented assessments.
F 0677: The facility failed to provide adequate assistance for transfers to Resident #18, who required two-person assistance but was transferred by one staff member, resulting in a fall.
F 0689: The facility failed to ensure Resident #124 was provided with wheelchair leg rests during transport by Physical Therapist #1, resulting in the resident's left leg being caught under the wheelchair and sustaining a left femur fracture.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Deficiency counts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #3 | Named in abuse finding involving Resident #142 | |
| Certified Nursing Assistant (CNA) #4 | Named in fall incident involving Resident #18 | |
| Physical Therapist (PT) #1 | Named in wheelchair accident involving Resident #124 | |
| LPN #2 | Licensed Practical Nurse | Named in failure to document vital signs for Resident #356 |
| RN #5 | Registered Nurse | Initiated accident report for Resident #18 fall |
| MD #1 | Physician | Provided orders and statements related to Resident #124 and Resident #356 |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 13, 2023
Visit Reason
Level 2 deficiency for reporting to national health safety network with widespread scope, not corrected at time of report.
Findings
Level 2 deficiency for reporting to national health safety network with widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 12, 2022
Visit Reason
Level 2 deficiency for reporting to national health safety network with widespread scope, not corrected at time of report.
Findings
Level 2 deficiency for reporting to national health safety network with widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 31, 2022
Visit Reason
Level 2 deficiency for reporting to national health safety network with widespread scope, not corrected at time of report.
Findings
Level 2 deficiency for reporting to national health safety network with widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 9, 2021
Visit Reason
The inspection was a Recertification survey conducted to assess compliance with pharmaceutical service requirements in the nursing facility.
Findings
The facility failed to provide pharmaceutical services that ensure accurate acquiring, receiving, dispensing, and administering of drugs. Expired medications were found in emergency boxes on 3 of 7 nursing units, and the facility lacked documentation that emergency box medications had been checked since March 2020.
Deficiencies (1)
F 0755: The facility did not provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Expired medications were found in emergency boxes on multiple nursing units.
Report Facts
Expired medications found: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed and stated she did not know who was responsible for checking expiration dates of medications | |
| Licensed Practical Nurse (LPN) #2 | Interviewed and stated she did not know who was responsible for checking expiration dates but believed pharmacist was responsible | |
| Licensed Practical Nurse (LPN) #3 | Interviewed and stated she did not know who was responsible for checking expiration dates of medications | |
| Director of Nursing Services | Interviewed and stated pharmacist was responsible for checking emergency boxes monthly but had not done so since March 2020 due to COVID-19 |
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