St Johnsville Rehabilitation And Nursing Center
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
resided on the A unit and wandered the facility a lot and was supposed to be closely watched, as there have been multiple incidents with them and other residents.During an interview on 08/29/2025 at 3:15 PM, Certified Nurse Aide #2 stated they were not working that day of the incident but knew the residents well.
They stated that Resident #89 wandered a lot throughout the facility and should have been observed when not on the unit. They stated they were unsure whether or not they were being observed. uring an interview
on 8/29/2025 at 10:25 AM, Licensed Practical Nurse #3 stated that they remembered the incident. They stated that Resident #89 was next to the other resident when they attempted to move them and separate them. They stated that they did not get to them in time, and Resident #89 was sprayed in the face with hot sauce. They stated that they removed the resident, rinsed the patient's face, and flushed their eye. They stated that they reported the incident to their supervisor. Attempted phone interview on 09/02/2025 at 12:35 PM with Registered Nurse #2, who was the Director of Nursing at the time of the incident, was unsuccessful. Resident #109Resident #109 was admitted to the facility with dementia with behavior disturbances (behavioral and psychological symptoms that accompany dementia, affecting a significant portion of those living with the condition), chronic obstructive pulmonary disease (a group of lung diseases that cause airflow obstruction and breathing difficulties), and hypertension (a condition where the force of your blood against the walls of your arteries is too high). The Minimum Data Set, dated [DATE REDACTED], documented that Resident #109 sometimes made themselves understood, sometimes understand others, and had severe cognitive impairment.The facility's Investigative Report dated 6/10/2025 documented that Resident #109 was walking in the hall toward Resident #89. Resident #89 struck Resident #109 with their walker, and Resident #109 retaliated and struck Resident #89 with a closed fist. The report documented that the force of both strikes was not strong enough to cause injury, and residents were separated. It was documented that neither resident was in their respective units. A review of progress notes dated 6/10/2025 at 4:52 PM, documented that Resident #109 was ambulating down the B unit hallway when Resident #89 started to hit them with their walker. Resident #109 turned and struck Resident #89 in the face with a closed fist. Nursing aides immediately separated residents. Upon assessment, Resident #109 did not have any injuries and had no recollection of the incident due to memory impairment.During an interview on 08/27/2025 at 3:35 PM, Certified Nurse Aide #1 stated that they remembered the incident and saw it happen. They stated that Resident #89 struck Resident #109 with their walker, and Resident #109 then struck Resident #89. They immediately responded and separated both residents. They stated that the residents reside in unit A and frequently wander the facility. They stated that they frequently saw Resident #89 striking individuals with their walker or running into them in the hallway. During an interview on 08/29/2025 at 3:15 PM, Certified Nurse Aide #2 stated that they remembered the incident and saw it happen. They stated that Resident #89 struck Resident #109 with their walker, and Resident #109 then struck Resident #89. They immediately responded and separated both residents. They stated that the residents reside in unit A and frequently wander the facility. They stated that they frequently see Resident #89 striking individuals with their walker or running into them in the hallway. During an interview on 09/02/2025 at 12:10 PM, Director of Nursing #1 stated there should be a mechanism to monitor behaviors if that's what the care plan says. Attempted phone interview on 09/02/2025 at 12:35 PM with Registered Nurse #2, who was the Director of Nursing at the time of the incident, was unsuccessful. 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)
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ST JOHNSVILLE REHABILITATION AND NURSING CENTER in SAINT JOHNSVILLE, NY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAINT JOHNSVILLE, NY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ST JOHNSVILLE REHABILITATION AND NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.