St. Joseph's Hospital - Skilled Nursing Facility
Non profit - Corporation
85 Beds
Independent
Data: November 2025
Trust Grade
73/100
#235 of 594 in NY
Photo by Tracy Lisk
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
St. Joseph's Hospital - Skilled Nursing Facility in Elmira, New York, has a Trust Grade of B, indicating it is a good choice, but there is room for improvement. It ranks #235 out of 594 facilities in New York, placing it in the top half, and #3 out of 4 in Chemung County, meaning only one local option is better. The facility's performance has been stable, with the same number of issues reported in both 2022 and 2024. Staffing is rated 4 out of 5 stars, although turnover is at 44%, which is average for the state. However, it has concerning RN coverage, being lower than 89% of New York facilities, which may hinder the quality of care. On the downside, there have been some serious incidents, including a medication error where a resident did not receive their anti-seizure medication and subsequently experienced seizure-like activity that required hospitalization. Additionally, the facility failed to complete baseline care plans for several residents within the required timeframe, and there were issues with food safety in the kitchen, with unlabeled and undated items present. While the facility has strengths, such as staffing stability and good overall ratings, these weaknesses should be carefully considered by families looking for care.
- Trust Score
- B
- In New York
- #235/594
- Safety Record
- Moderate
- Inspections
- Holding Steady
- Staff Stability ○ Average
- 44% turnover. Near New York's 48% average. Typical for the industry.
- Penalties ✓ Good
- $4,194 in fines. Lower than most New York facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for New York. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 11 deficiencies on record. Higher than average. Multiple issues found across inspections.
73/100
Top 39%
Needs review
3 → 3 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2022: 3 issues
2024: 3 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below New York average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
Staff Turnover: 44%
Near New York avg (46%)
Typical for the industry
Federal Fines: $4,194
Below median ($33,413)
Minor penalties assessed
The Ugly 11 deficiencies on record
1 actual harm
Jul 2024
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0836
(Tag F0836)
Could have caused harm · This affected 1 resident
Based on observations and interview conducted during the Recertification Survey from 7/22/24-7/26/24, the facility did not ensure compliance with all applicable State codes. Specifically, the facility...
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Based on observations and interview conducted during the Recertification Survey from 7/22/24-7/26/24, the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are:
Observations on 7/23/24 at 10:40 AM included a carbon monoxide detector located on the wall in the Energy Center that housed the 500-Kilowatt (kW) generator.
During an interview on 7/24/24 at 2:35 PM, the Facilities Manager asked the surveyor how often the facility is supposed to test the carbon monoxide detectors. When the surveyor responded that they need to be inspected/tested monthly, the Facilities Manager stated that they are probably not doing that monthly. There was no additional documentation provided by the facility of the locations of all carbon monoxide detectors within the facility, nor was their documentation of monthly inspections and testing of carbon monoxide detectors.
Observations on 7/25/24 at 12:25 PM included a natural gas range in the main kitchen and a carbon monoxide detector on the wall outside the staff dining area in the middle of the kitchen.
The 2015 edition of the International Fire Code (IFC), requires carbon monoxide detection to be provided in an approved location between the fuel burning appliance and the dwelling unit, sleeping unit, or classroom; or on the ceiling of the room containing the fuel-burning appliance. Additionally, carbon monoxide alarms shall be maintained in accordance with NFPA 720. The 2012 Edition of NFPA 720, Standard for the Installation of Carbon Monoxide Detection and Warning Equipment, requires that single-station carbon monoxide alarms shall be inspected and tested in accordance with the manufacturer ' s published instructions at least monthly.
10 NYCRR: 415.29(a)(2), 711.2(a)(1);
42 CFR: 483.70(b),
2015 IFC: Section 915, 915.1, 915.1.4, Section 1103.9,
2012 NFPA 720: 8.7.1
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification Survey from 7/22/24-7/26/24, for 7 (Residents #27, #3...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the Recertification Survey from 7/22/24-7/26/24, for 7 (Residents #27, #35, #36, #38, #58, #66, #76) of 14 residents reviewed, the facility did not ensure the baseline care plan (developed within 48 hours of admission and included minimum healthcare information necessary to properly care for the immediate needs of the residents, that they were able to understand) was completed within 48 hours of a resident's admission and that a summary of the baseline care plan was provided to the resident and/or their representative. Specifically, for Resident #36, #38, #58, #76, the facility could not provide documented evidence that a baseline care plan was completed within 48 hours of the resident's admission. For Residents #27, #66, and #73, the facility could not provide evidence that a summary of the baseline care plan was provided to the resident and/or their representative. The findings include, but was not limited to, the following:
Review of the facility policy Baseline (48-Hour) Care Plan, dated July 2024, revealed that the baseline care plan would be developed within 48 hours of a resident's admission and include an initial set of instructions needed to provide effective and person-centered care for the resident. Additionally, the policy documented the baseline care plan would be shared with the resident and/or the residents representative.
1. Resident #28 was admitted to the facility with diagnoses that included breast cancer, history of transient ischemic attack (mini stroke), and anxiety. The Minimum Data Set Resident assessment dated [DATE], documented the resident was cognitively intact.
Review of the electronic health record for Resident #28 did not include documented evidence that a baseline care plan had been completed.
The facility was unable to provide any documented evidence that the resident's baseline care plan had been completed and that a summary had been provided to the resident.
2. Resident #36 was recently admitted to the facility with diagnoses including a fracture of the upper right arm, congestive heart failure, and gout. The Minimum Data Set Resident assessment dated [DATE], revealed the resident was severely cognitively impaired.
Review of the electronic health record for Resident #36 did not include any documented evidence that a baseline care plan had been completed following admission to the facility.
The facility was unable to provide any documented evidence that a baseline care plan had been completed for Resident #36 and a summary provided to the resident's representative.
3. Resident #27 was admitted to the facility with diagnosis including a fracture of the upper arm, dementia, and type 2 diabetes mellitus. The Minimum Data Set Resident assessment dated [DATE], revealed the resident had moderately impaired cognition.
Resident #27's baseline care plan, signed by Registered Nurse Clinical Coordinator #1 on 5/7/24, did not include that a summary of the baseline care plan had been reviewed with the resident and/or their representative.
During an interview on 7/25/24 at 1:35 PM, Registered Nurse Clinical Coordinator #1 stated nurse managers or the nurse admitting the resident are responsible for baseline care plans and providing a copy to the resident and/or their representative. Registered Nurse Clinical Coordinator #1 stated that they were completing the baseline care plans on an electronic health system and in that health system there is not anything that reminds the nurses to complete a baseline care plan.
In an interview on 7/25/24 at 4:06 PM, the Director of Nursing stated that within 48 hours of admission the resident should have a baseline care plan started with their immediate needs and that it should be reviewed with the resident and/or the resident representative. The Director of Nursing stated the electronic health system did not make it obvious that a baseline care plan needed to be completed and that they have some newer staff that may not have gotten the training or the understanding to complete the baseline care plans.
10 NYCRR 415.11
MINOR
(B)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected multiple residents
Based on observations, interviews, and record review conducted during a Recertification Survey from 7/22/24-7/26/24, the facility did not ensure the nurse staffing information was posted with the requ...
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Based on observations, interviews, and record review conducted during a Recertification Survey from 7/22/24-7/26/24, the facility did not ensure the nurse staffing information was posted with the required information and in a prominent place readily accessible to all residents and visitors. Specifically, the nurse staffing information did not consistently include the accurate number and total hours worked by licensed (Registered Nurses and Licensed Practical Nurses) and unlicensed (Certified Nurse Aides) nursing staff who were directly responsible for resident care. Additionally, the staffing information was only posted on one residential unit preventing access of the information to the residents and visitors on the second unit (a secured unit that was locked and required staff to provide elevator access to all residents or visitors). This is evidenced by the following:
During observations on 7/24/24 at 12:16 PM and 4:04 PM and 7/25/24 at 1:46 PM, the facility's nurse staffing information posted did not include the actual and total hours worked for both licensed and unlicensed nursing staff. Additionally, the nurse staffing postings were located on the third-floor residential care unit, which was not accessible to residents or visitors on the fifth floor without staff assistance (badge access).
Review of the daily nursing information from 6/1/24 to 7/24/24 revealed multiple days that did not include the accurate number of Registered Nurses (Registered Nurse Supervisors not included) when reviewed with the staffing schedules.
During an interview on 7/24/24 at 12:30 PM, the Director of Nursing stated that the facility had 24-hour Registered Nurse Supervisor coverage in the facility at all times (7 days a week).
During an interview on 7/25/24 at 8:30 AM, Scheduler #1 said they schedule staff and complete the daily nursing staffing postings. Scheduler #1 said they go over nursing staff with the Director of Nursing each morning, complete the nursing staff form for the day shift, and post it. Scheduler #1 said they would fill out the second part (evening shift staffing) around 3:15 PM, and they would complete the night shift staff the next morning (after the shift) when the posting is removed and the new day's information posted. Scheduler #1 said the purpose of the daily nursing staffing posting is to show they have adequate nursing staffing. Scheduler #1 said the daily nursing staffing is posted on the third floor (across from a nurses' station) and included the number of registered nurses, licensed practical nurses, and certified nurse aides (registered nurse supervisors not included). Scheduler #1 said they were not aware that the total number of hours worked by each discipline was required to be on the postings. Scheduler #1 said the daily nurse staffing was posted in one location in the facility (on the third-floor resident unit). If a resident (or visitor) on the fifth-floor resident unit wanted to observe it, they could ask staff who could provide a copy of the information, but that residents or visitors would not know the information was posted on the third floor if they had never been there.
During an interview on 7/26/24 at 12:20 PM with the Administrator and the Director of Nursing, the Director of Nursing stated that both the number of each nursing discipline and the total hours worked by each were required to be on the daily nurse staffing posting. The Director of Nursing said they were not aware that the total hours worked was also required and were not sure why the information was only posted on one unit.
10 NYCRR 415.13
Apr 2022
3 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during a Recertification Survey and a complaint investigation (NY...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during a Recertification Survey and a complaint investigation (NY00279223), from 3/39/22 to 4/1/22, the facility failed to ensure that one (Resident #7) of five residents reviewed was free of significant medication errors. Specifically, Resident #7 was not provided Keppra (an anti-seizure medication) as ordered and subsequently experienced seizure-like activity requiring hospitalization. This resulted in actual harm to Resident #7 that was not immediate jeopardy.
Findings include:
Resident #7 had diagnoses including Alzheimer's dementia, seizure disorder, and Down Syndrome. The Minimum Data Set assessment dated [DATE], documented the resident's cognition as severely impaired and that the resident required extensive assistance for activities of daily living.
Physician orders dated 6/3/21, included Keppra 750 milligrams twice daily at 6:00 a.m., and 6:00 p.m. for seizures.
Review of the Medication Administration Record (MAR) for 6/28/21- 7/2/21 documented that 7 out of 10 opportunities for the Keppra were documented as not being administered with the first missed dose on 6/28/21 6:00 a.m.
In a nursing progress note dated 7/2/21 at 9:32 p.m., Registered Nurse (RN)/ Clinical Coordinator #1 documented that Resident #7 did not receive their Keppra medication as ordered due to the medication being unavailable. RN/Clinical Coordinator #1 wrote they were notified by staff to come to Resident #7's room where the resident was having seizure-like activity. Vital signs revealed an elevated blood pressure of 181/85, and the resident was transferred to the hospital.
A review of the resident's lab work dated 7/2/21 documented Keppra levels were < 2 with a normal reference range of 12 to 46.
A review of the facility's Investigation Report documented that Resident #7's MAR had multiple missed doses of the Keppra with nursing notes stating the medication was not available. In a statement given on 7/9/21, Licensed Practical Nurse (LPN) #1 stated they had discovered on 6/29/21 that the Keppra medication for Resident #7 was circled as not administered for the morning dose and that the medication was not in the medication cart. LPN #1 then stated they were able to administer Resident #7 medication but was unable to provide details as to where they obtained the medication. The Investigation Report included a message from the pharmacy that Resident #7's Keppra was ordered on 5/31/21 and then not until 7/2/21 at 9:37 p.m.
Review of Resident #7's medical record and the Investigation Report documented there was no documented evidence that the physician was notified of any missed doses of Keppra.
There was no documented evidence the facility requested refills for Resident #7's Keppra refill until after the resident was transferred to the hospital.
During an interview on 3/31/22 at 7:54 a.m., LPN #2 stated they were aware of the issue at the time and that the Keppra medication for Resident #7 had been running low and that two attempts had been made to the facility's contracted pharmacy requesting a refill of the medication. LPN#2 stated they were then off for two days and when they returned to work, Resident #7 still had not received the medication. LPN #2 stated they did not notify the provider as they would only notify the provider if the resident had missed a dose because there are other ways to get a medication and thought this may have occurred.
During an interview on 3/31/22 at 8:36 a.m., the Pharmacist stated that Resident #7 had an order to refill the Keppra but did not receive an order from the facility until 7/2/21 at 9:37 p.m. (at the time of discharge to the hospital).
During an interview on 3/31/22 at 9:46 a.m., the RN/Clinical Coordinator #1 stated they were working the evening shift the night the resident was transferred to the hospital and when they attempted to pull Resident #7's 6:00 p.m. medications, they could not locate the Keppra. The RN/Clinical Coordinator #1 stated they could see on the MAR that the resident had missed some doses of the Keppra medication previously but could not recall how many. The RN/Clinical Coordinator #1 stated that they were called into the resident's room and discovered that Resident #7 was having seizure-like activity and was sent to the hospital.
During an interview on 3/31/22 at 12:50 p.m., the Director of Nursing (DON) stated they were first notified of the medication administration issues on 7/2/21 after Resident #7 was transferred to the hospital. The DON stated the nurses document their initials on the MAR to represent the medication as administered or the nurses will place their initials and a circle to represent the medication were not administered. The DON stated they had provided education to their staff about leaving holes on the MAR and that if a nurse forgets to document they have 48 hours to update the MAR. The DON stated that during their investigation they received mixed statements from nursing regarding the missed doses and was unable to come to a conclusion about the number of missed doses and the reason for them. The DON stated they were told by one nurse that a bottle of Keppra had been requested by the pharmacy and delivered but the that the nurse had thrown out the copy of the fax information and no proof was found of the request. The DON stated they were also told by nursing that another resident on the unit was receiving the same medication as Resident #7 and that the medication was borrowed and provided to Resident #7.
During an interview on 3/31/22 at 2:04 p.m., the Physician stated they would want to be notified if a single dose of a medication was missed. The physician stated if an individual does not receive their anti-seizure medication, they can have a seizure.
10NYCRR 415.12(m)(2)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interviews and record reviews, conducted during the Recertification Survey, completed on 4/1/22, it was determined that for one of one main kitchen, the facility failed to store...
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Based on observations, interviews and record reviews, conducted during the Recertification Survey, completed on 4/1/22, it was determined that for one of one main kitchen, the facility failed to store, prepare, distribute and serve food in accordance with professional standards (U.S. Food and Drug Administration's Food Code) for food service safety. Specifically, there were multiple undated and unlabeled food items and non-food contact surfaces within the kitchen were not maintained in clean and sanitary condition. This is evidenced by the following:
The facility policy, 'Food Storage', reviewed/revised June 2021, included that all products are to be labeled and dated with the receiving date. The policy included that old supplies should be moved to the front of the shelf to ensure rotation of products and new supplies should be placed to the rear of the shelf. The policy included that storerooms, refrigeration units and freezers should be mopped and swept as scheduled and as needed.
The facility policy, 'Cleaning and Sanitizing of Work Surfaces', reviewed/revised June 2021, included that a cleaning schedule is completed and posted to ensure routine cleaning is completed weekly. Larger pieces of equipment and areas are scheduled on a biweekly and monthly basis. The policy included that when cleaning fixed equipment, non-removable parts are cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution at the appropriate concentration. The equipment is reassembled, and any food contact surfaces that may have been contaminated during the process are re-sanitized.
Observations during the initial brief tour of the main kitchen on 3/29/22 from 9:40 a.m. to approximately 10:40 a.m. revealed the following:
a. Three bags of instant gravy mix, two bags of powdered mashed potato, three bags of potato pearls, and three 10-pound (lb.) bags of pasta were all open and undated, in the dry storage area.
b. A case of eight-ounce (oz.) cans containing tube feed (liquid form of nourishment), expired December 2021, remained on the shelf in the dry storage area.
c. A 32oz. container of liquid egg product, a container of horseradish and a container of vegetable base were open, partially used and undated in a walk-in cooler.
d. A bag of fries, a bag of hash brown potatoes, a bag of cheese tortellini, a tray of cheese manicotti, a 5lb. bag of meat balls, a 10lb. bag of cod nuggets, a 10lb. bag of scallops and a large box of tilapia patties and a box of French loaf garlic slices were all open and undated, in a walk-in freezer. The was also an undated 32oz. jar of bruschetta without a lid and a broken rim, covered in plastic.
e. A undated and unlabeled grocery bag of what was identified as decayed parsley, in the produce cooler.
f. A 5lb. container of sour cream was open, partially used and undated in a walk-in cooler.
g. Ten portioned cups of grapes were undated and three portioned cups of what was identified as pureed cottage cheese were undated and unlabeled, in a walk-in cooler.
h. Sticky floors were identified in the nourishment cooler.
i. A sheet tray each of prepared cups of what was identified as applesauce, grapes, butterscotch pudding and tossed salad were all uncovered, unlabeled and undated, in a stand-up refrigerated unit.
j. An open, undated box of raspberries and a shelving unit that was covered in crumbling food debris, and large white and pink dried drips on it in the deep freezer.
Observations during the follow-up tour of the main kitchen on 3/31/22 at 11:10 a.m. revealed the following:
a.
A food processor that was not air-dried after sanitizing and remained wet when ready to be stored.
b.
A bag of pizza crusts that were open and undated, in a walk-in freezer. The 10lb. bag of cod nuggets and box of tilapia remained open and undated from two days prior.
c.
Readily accessible and exposed piping behind and next to two steam jacketed kettles that were in the cook's area were covered in thick green, black and brown grime. The grime was easily scraped by the surveyor's fingernail.
d.
Walls in the cook's area were covered in dried-on tan drips.
e.
Hot-holding equipment and an oven in the cook's area were covered in dried-on tan drips and food debris.
During an interview on 3/31/22 at 12:03 p.m., the Kitchen Aide stated they didn't know what the grime and debris on the pipes was. The Kitchen Aide said that the cook's area needed to be cleaned and that the big equipment was usually cleaned on the weekends.
During an interview on 3/31/22 at 12:35 p.m., the Kitchen Support Manager stated that they did not know how to clean the cook's prep area equipment and pipes and thought that it was previously power sprayed. The Kitchen Support Manager said that it was in the job description for each shift what should have been done for cleaning.
10NYCRR: 415.14(h)
10NYCRR: 14-1.10, 14-1.21, 14-1.110, 14-1.116, 14-1.171
U.S. Food and Drug Administration's (FDA) Food Code
Centers for Disease Control and Prevention's (CDC) food safety guidance
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0582
(Tag F0582)
Minor procedural issue · This affected multiple residents
Based on interviews and record reviews conducted during the Recertification Survey, completed on 4/1/22, it was determined that for two (Resident #64 and #73) of three residents reviewed, the facility...
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Based on interviews and record reviews conducted during the Recertification Survey, completed on 4/1/22, it was determined that for two (Resident #64 and #73) of three residents reviewed, the facility did not provide the appropriate appeal notice to the Medicare beneficiary in order to notify them of their appeal rights under the regulations. Specifically, the facility did not provide the Medicare A beneficiaries with a Notice of Medicare Non-Coverage (NOMNC) letter prior to discharge from the facility per the regulations. This is evidenced by:
Resident #64 was admitted to the facility 3/2/22 under Medicare part A benefits and was discharged to the community on 3/18/22. There was no documented evidence that the resident or responsible party was provided with and properly completed the required appeal notice prior to discharge.
Resident #73 was admitted to the facility 1/17/22 under Medicare part A benefits and was discharged to the community on 1/27/22. There was no documented evidence that the resident or responsible party was provided with and properly completed the required appeal notice prior to discharge.
In an interview on 4/1/22 at 11:05 a.m., the Social Worker (SW) stated that signed NOMNC forms were not completed for Resident's #64 and #73 because they did not know they had to be completed.
In an interview on 4/1/22 at 11:40 a.m., the Administrator stated the SW was responsible for completing NOMNC forms and was not aware SW did not issue the right forms.
10 NYCRR 415.3(g)(2)(i)
Jan 2020
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of three resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of three residents reviewed for resident right's, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries to notify them of their appeal rights under the regulation. Specifically, Resident #44 did not receive a Skilled Nursing Facility Advanced Beneficiary Notice or a denial letter at the termination of Medicare Part A benefits. This is evidenced by the following:
Resident #44 was admitted to the facility on [DATE] and was discontinued from Medicare Part A services on 12/6/19 and remained in the facility. There was no evidence that a Skilled Nursing Facility Advanced Beneficiary Notice or denial letter was given to the resident or legal representative informing them of their potential liability for payment.
When interviewed on 1/23/20 at 11:30 a.m., the Licensed Practical Nurse responsible for billing said she was new to the position, and had just started learning about liability notices. At that time, the Administrator said that the person who did the job for 30 years had retired and they were in the process of learning her job.
[10 NYCRR415.3(g)(2)(i)]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of three residents reviewed for non-pressure related skin conditions, ...
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Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of three residents reviewed for non-pressure related skin conditions, the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs. Specifically, Resident #17 had documented combative behaviors, was at a high risk for skin impairment, and did not have a care plan developed to address behaviors or skin impairment, and Resident #61 had a history of bruising with newly identified bruises on 1/23/20 and there was no care plan in place to address the resident's risk for skin impairment. This is evidenced by the following:
1.
Resident #17 had diagnoses including dementia, agitated depression, and osteoarthritis. The Minimum Data Set (MDS) Assessment, dated 11/11/19, revealed the resident had severely impaired cognition.
Review of Injury of Unknown Origin Investigation Reports revealed that the resident was found to have sustained a skin tear to the right shin on 12/13/19. The resident was combative during cares and sustained skin tears on 12/15/19 and 1/20/20.
The current Active Care Plan did not address the resident's risk for skin impairment or behaviors.
When observed on 1/21/20 at 11:15 a.m., the resident was noted to have a skin tear to her right forearm and several areas of possible bruising that were purple and red in color.
When interviewed on 1/24/20 at 10:08 a.m., Registered Nurse (RN) Unit Coordinator #1 stated that based on nursing judgment, Geri-sleeves and leg sleeves were placed on the resident after sustaining skin tears. She said the leg sleeves were placed on the resident for protection following an incident that resulted in skin tears but were not continued after the area healed. She said the resident's care plan should address the resident's behavior and any factors placing the resident at risk for skin tears including interventions, but it does not.
2.
Resident #61 had diagnoses including chronic kidney disease, syncope, and gait instability. The MDS Assessment, dated 12/27/19, revealed the resident had moderately impaired cognition.
Review of Injury of Unknown Origin Investigation Reports revealed that the resident was found to have a bruise to the right foot on 11/3/19, a bruise to the right elbow on 11/6/19, and bruises to the left lower leg and left hand on 1/23/20.
The Active Care Plan, dated 1/7/20, and the Door Care Plan, dated 11/6/19, did not include resident specific needs or precautions related to the resident's history of bruising.
During an observation on 1/21/20 at 2:00 p.m., the resident was observed to have localized swelling and bruising that was purple and blue in color noted to the left hand at the joint between the thumb and forefinger. On 1/23/20 at 10:16 a.m., the resident was observed to have localized swelling and bruising that was purple and blue in color to her left lateral ankle.
Interviews conducted on 1/24/20 included the following:
a. At 11:20 a.m., RN Unit Coordinator #2 stated the resident should have had a care plan in place for fragile skin. She said interventions were put into place including a new chair, padding to the chair, and removal of a bed assist rail.
b. At 1:22 p.m., the Director of Nursing (DON) stated that interventions had been put into place as a result of past bruises. After review of the resident's Active Care Plan at that time, the DON stated that it did not address the resident's risk for bruising or skin tears and does not include interventions that were implemented after previous incidents of bruising. She said the resident's risk for bruising should be addressed in the Active Care Plan or Door Care Plan.
c. At 1:25 p.m., the Administrator stated that every resident admitted to the facility should have a care plan that addresses skin integrity. She said if a resident was identified as having frequent bruising or skin tears, there should be a care plan in place including interventions.
[10 NYCRR 415.11(c)(1)]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #55) of one resident reviewed for infections, the facility d...
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Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #55) of one resident reviewed for infections, the facility did not ensure proper infection control procedures were followed. Specifically, a staff member did not remove soiled gloves or wash their hands prior to touching surfaces in the room and handling a stack of clean briefs. This is evidenced by the following:
Resident #55 has diagnoses including clostridium difficile (C-diff, a bacterium that causes diarrhea and colitis - an inflammation of the colon), anxiety, and depression. The Minimum Data Set Assessment, dated 12/19/19, revealed the resident was cognitively intact.
The Active Care Plan, dated 1/13/20, revealed that the resident was positive for c-diff, was on contact precautions, and required the assistance of staff with personal hygiene after episodes of loose stools.
A progress note, dated 1/13/20, revealed the resident was on an antibiotic (Vancomycin) three times a day and was still having liquid mucous stools.
During an observation of care on 1/24/20 at 8:25 a.m., the Registered Nurse (RN) Unit Coordinator was observed wearing the appropriate personal protective equipment prior to contact with the resident. The resident's incontinence brief had a moderate amount of loose stool present. The nurse cleansed the resident's perineal area. She stated that there were no clean briefs in the room. Without removing her soiled gloves, the nurse touched the privacy curtain to open it, and then touched the room door handle to access the hallway. While standing in the doorway, the nurse alerted staff who were in the hallway to bring her clean briefs. The nurse received a stack of briefs with the soiled gloves, placed them on the resident's nightstand, and again touched the privacy curtain to close it. She then resumed performing incontinence care.
When interviewed on 1/24/20 at 8:50 a.m., the RN Unit Coordinator stated that she did not think to remove her gloves, but should have removed her gloves. She should have washed her hands prior to touching the privacy curtain and the door handle.
During an interview on 1/24/20 at 11:48 a.m., the Infection Preventionist stated that staff should not be touching any surfaces with soiled gloves. She said if a resident has c-diff, surfaces that were touched with contaminated gloves should be cleaned. She said gloves should be removed, and hands should be washed with soap and water prior to leaving the room.
When interviewed on1/24/20 at 1:18 p.m., the Director of Nursing stated that if a resident was on contact precautions, she would have expected the nurse to remove her gloves and wash her hands before touching any surfaces in the room.
[10 NYCRR 415.19(a)(1-4)]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (one Housekeeping employee and one Certified Nurse Assistant) of eight employees reco...
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Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (one Housekeeping employee and one Certified Nurse Assistant) of eight employees records reviewed, the facility did not properly implement policies and procedures to prevent abuse. Specifically, the facility did not conduct a Nurse Aide Registry Check prior to hiring employees. This is evidenced by the following:
A review of the facility records on 1/23/20 from 2:05 p.m. to 2:55 p.m. revealed one Housekeeping employee began work at the facility on 9/16/19 with no proof of Nurse Aide Registry verification prior to their start date. Further record review of the employee's time detail report revealed the employee worked the following dates: 9/16/19, 9/17/19, 9/19/19, 9/20/19, 9/23/19, 9/24/19, 9/25/19, 9/27/19, 9/28/19, and 9/29/19. Additionally, a timestamp of 1.25 hours was also recorded in the time detail report on 10/4/19.
During an interview on 1/23/19 at 2:25 p.m., the Human Resources Manager stated she was unable to locate the Nurse Aide Registry verification for the Housekeeping employee. She stated that the employee was removed from the work schedule on 10/3/19 due to a pending denial letter from the CHRC. She stated the Housekeeping employee was terminated on 12/9/19 due to a final denial letter from the CHRC.
A review of the facility records on 1/23/20 from 2:05 p.m. to 2:55 p.m. revealed one Certified Nurse Assistant (CNA) began work at the facility on 1/14/20, and a Nurse Aide Registry verification was completed on 1/23/20.
During an interview on 1/23/20 at 2:35 p.m., the Human Resources Manager stated she was certain the Nurse Aide Registry verification was performed prior to the CNA's start date, but she was unable to locate that record. She stated that the CNA was unable to use the normal time tracking system, and her work hours were recorded by her nursing supervisor.
On 1/24/20 at approximately 2:00 p.m., a copy of the CNA's work schedule was provided for the surveyor to review. Review of the CNA's work schedule revealed she worked the following dates without a Nurse Aide Registry verification: 1/17/19 (7:00 a.m. Start), 1/20/19 (7:00 a.m. Start), 1/22/19 (7:00 a.m. Start), and 1/23/19 (7:00 a.m. Start).
[10 NYCRR 415.4(b)(1)(ii)(b)]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that that f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that that for one of one main kitchen, the facility did not prepare, distribute, and store food under sanitary conditions. The issues involved grilled ham and cheese sandwiches that were not hot held at the proper temperature for food service, improper freezer and dry storage, and the use of metal scouring pads. This is evidenced by the following:
The facility's policy, HACCP and Food Handling Principles, dated February 2010, included that hot foods are to be served at between 140 degrees Fahrenheit (*F) to 155*F.
The facility's policy, Cleaning and Sanitizing of Work Surfaces, dated July 2018, revealed that a nylon-scouring pad is used as an abrasive to remove food soil from surfaces. Steel wool and metal scouring pads are not permitted.
The initial tour of the kitchen on 1/21/20 at 10:30 a.m. and a subsequent tour on 1/23/20 at 11:30 a.m. revealed the following:
a. A steel wool, metal scouring pad was in use in the cook's area. The Food Service Director said the steel scouring pad was used to scrub the macaroni and cheese out of the soup kettles. He said that he was unaware that the metal scouring pads were not allowed.
b. The facility's two freezers had boxes stored a few inches from the ceiling, and in Freezer #1 there were two boxes wedged below the fan.
c. The dry storeroom had four boxes of coffee lids on the floor. The Food Service Director said the boxes should not have been on the floor.
During an observation of the lunch tray line on 1/23/20 at 11:45 a.m., there were grilled ham and cheese sandwiches on the tray line that were stacked three layers high in a steam table pan. Using the facility [NAME] Aqua Tuff 351 digital thermometer, the Food Service Director inserted the thermometer into the top layer of sandwiches under the light (in the back of the pan) and it registered 110*F, and the front of the pan registered 88*F. The second layer of grilled ham and cheese sandwiches registered at 112*F. When interviewed at that time, the Food Service Director said the temperature should be at least 135*F, and then asked the cook to send the top two layers of grilled ham and cheese sandwiches to be reheated.
When interviewed on 1/24/20 at 10:00 a.m. the Food Service Director said that he ideally wants the hot food at 160*F on the steam table.
[10 NYCRR 415.14(h), 14-1.43, 1.40, 1.90]
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • $4,194 in fines. Lower than most New York facilities. Relatively clean record.
- • 44% turnover. Below New York's 48% average. Good staff retention means consistent care.
Concerns
- • 11 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 73/100. Visit in person and ask pointed questions.
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About This Facility
What is St. Joseph'S Hospital - Skilled Nursing Facility's CMS Rating?
CMS assigns St. Joseph's Hospital - Skilled Nursing Facility an overall rating of 4 out of 5 stars, which is considered above average nationally. Within New York, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is St. Joseph'S Hospital - Skilled Nursing Facility Staffed?
CMS rates St. Joseph's Hospital - Skilled Nursing Facility's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 44%, compared to the New York average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at St. Joseph'S Hospital - Skilled Nursing Facility?
State health inspectors documented 11 deficiencies at St. Joseph's Hospital - Skilled Nursing Facility during 2020 to 2024. These included: 1 that caused actual resident harm, 8 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates St. Joseph'S Hospital - Skilled Nursing Facility?
St. Joseph's Hospital - Skilled Nursing Facility is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 85 certified beds and approximately 77 residents (about 91% occupancy), it is a smaller facility located in Elmira, New York.
How Does St. Joseph'S Hospital - Skilled Nursing Facility Compare to Other New York Nursing Homes?
Compared to the 100 nursing homes in New York, St. Joseph's Hospital - Skilled Nursing Facility's overall rating (4 stars) is above the state average of 3.1, staff turnover (44%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting St. Joseph'S Hospital - Skilled Nursing Facility?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is St. Joseph'S Hospital - Skilled Nursing Facility Safe?
Based on CMS inspection data, St. Joseph's Hospital - Skilled Nursing Facility has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in New York. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at St. Joseph'S Hospital - Skilled Nursing Facility Stick Around?
St. Joseph's Hospital - Skilled Nursing Facility has a staff turnover rate of 44%, which is about average for New York nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was St. Joseph'S Hospital - Skilled Nursing Facility Ever Fined?
St. Joseph's Hospital - Skilled Nursing Facility has been fined $4,194 across 1 penalty action. This is below the New York average of $33,121. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is St. Joseph'S Hospital - Skilled Nursing Facility on Any Federal Watch List?
St. Joseph's Hospital - Skilled Nursing Facility is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.