Inspection Reports for
St Johnland Nursing Center, Inc
395 Sunken Meadow Road, Kings Park, NY, 11754
Back to Facility Profile6 Reports
Inspection Report — Feb 25, 2026
Complaint Investigation State
Date: Feb 25, 2026
Visit Reason
State-compiled facility profile showing 17 inspections from 2022 to 2026 with citation and enforcement history.
Complaint Details
The state logged 100 complaints about this facility; 23 led to on-site inspections. This facility received 49.1 complaints per 100 beds vs. a statewide rate of 57.4. 13 citations resulted from those complaints (6.4 per 100 beds vs. 5.3 statewide).
Findings
Across 17 inspections, 8 resulted in citations totaling 39, including 25 standard health and 14 life safety code citations. The facility had 100 complaints with 23 on-site inspections and 5 enforcement actions totaling $58,000 in fines.
Citations (32)
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices issue noted on February 25, 2026.
Standard Health Citation — quality of care: Free From Abuse And Neglect issue noted on February 5, 2026.
Standard Health Citation — quality of care: Free From Abuse And Neglect issue noted on March 10, 2025.
Standard Health Citation — quality of care: Care Plan Timing And Revision issue noted on December 10, 2024.
Standard Health Citation — quality of care: Competent Nursing Staff issue noted on December 10, 2024.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan issue noted on December 10, 2024.
Standard Health Citation — quality of care: Food Procurement,store/prepare/serve-sanitary issue noted on December 10, 2024.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices issue noted on December 10, 2024.
Standard Health Citation — quality of care: Infection Prevention & Control issue noted on December 10, 2024.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals issue noted on December 10, 2024.
Standard Health Citation — quality of care: Provided Diet Meets Needs Of Each Resident issue noted on December 10, 2024.
Standard Health Citation — quality of care: Resident Call System issue noted on December 10, 2024.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights issue noted on December 10, 2024.
Standard Health Citation — quality of care: Sufficient Nursing Staff issue noted on December 10, 2024.
Life Safety Code Citation — NFPA requirements: Dietary Services issue noted on December 10, 2024.
Life Safety Code Citation — NFPA requirements: Elevators issue noted on December 10, 2024.
Life Safety Code Citation — NFPA requirements: Exit Signage issue noted on December 10, 2024.
Life Safety Code Citation — NFPA requirements: Fire Drills issue noted on December 10, 2024.
Life Safety Code Citation — NFPA requirements: Maintenance, Inspection & Testing - Doors issue noted on December 10, 2024.
Standard Health Citation — quality of care: Reporting - National Health Safety Network issue noted on January 2, 2024, not yet corrected.
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents issue noted on May 18, 2023.
Standard Health Citation — quality of care: Free From Abuse And Neglect issue noted on May 18, 2023.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices issue noted on May 18, 2023.
Standard Health Citation — quality of care: Infection Prevention & Control issue noted on May 18, 2023.
Standard Health Citation — quality of care: Resident Records - Identifiable Information issue noted on May 18, 2023.
Standard Health Citation — quality of care: Services Provided Meet Professional Standards issue noted on May 18, 2023.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System issue noted on May 18, 2023.
Life Safety Code Citation — NFPA requirements: Illumination Of Means Of Egress issue noted on May 18, 2023.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General issue noted on May 18, 2023.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing issue noted on May 18, 2023.
Standard Health Citation — quality of care: Reporting - National Health Safety Network issue noted on February 13, 2023, not yet corrected.
Standard Health Citation — quality of care: Reporting - National Health Safety Network issue noted on December 12, 2022, not yet corrected.
Report Facts
Inspections on page: 17
Total violations/deficiencies cited: 39
Inspections with violations: 8
Inspections without violations: 9
Total complaints: 100
On-site complaint inspections: 23
Citations from complaints: 13
Enforcement actions: 5
Total fines: 58000
Inspection Report — Mar 10, 2025
Abbreviated Survey CMS
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.
Citations (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 — Dec 10, 2024
Annual Inspection CMS
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.
Citations (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 — Dec 10, 2024
Abbreviated Survey CMS
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.
Citations (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 — May 18, 2023
Annual Inspection CMS
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.
Citations (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 — Apr 9, 2021
Annual Inspection CMS
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.
Citations (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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