Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Johnsville Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Failure to maintain resident dignity and respect: one resident with a urinary catheter was observed with the catheter bag exposed and at times dragging on the floor, while another resident reported being left for last because they were slow, overheard CNAs making disrespectful comments, and was told an aide was not "breaking my back" to move a raised toilet seat/commode setup. The resident also reported delayed toileting assistance, incontinence while waiting, and that urine on the floor was not cleaned up.
Failure to address significant resident weight changes. Three residents with diagnoses including paraplegia, dysphagia, acute kidney failure, diabetes, COPD, dementia, quadriplegia, and pulmonary hypertension had large unexplained weight changes, including major loss and gain, but the records did not show reweights or nutrition, MD, or RD follow-up. Staff stated residents should be weighed on admission/readmission, but weights were inconsistently entered into the EMR and one RD reported not receiving a requested reweigh.
Insufficient nursing staffing and delayed resident care: The facility did not maintain staffing levels consistent with its assessment, with multiple shifts falling below the required RN/LPN and CNA coverage. Residents reported long waits for care and being left unattended for extended periods, while a CNA confirmed that residents sometimes had to wait longer for assistance. The Administrator and Staffing Coordinator acknowledged that the facility was short-staffed at times and was working to reach the assessed staffing levels.
Daily nurse staffing information was not posted in an area readily visible or accessible to all residents and visitors. The postings were kept in a hallway at the far end of the building near HR, so visitors to the B and C units would have had to walk to the opposite end of the facility to view the staffing, while those near the A unit could see it when passing by. An SC stated the staffing list had always been posted there and that they did not know it needed to be in a different location.
Medication Error Rate Exceeded Allowed Threshold: Surveyors observed an 88% med error rate during 25 med pass observations. An LPN crushed multiple meds that were ordered to be taken whole for one resident, including several do-not-crush meds, and another LPN placed metoprolol succinate ER into the wrong cup and stated it had been crushed previously. The MARs showed the meds were ordered whole, and staff stated they were unaware of the do-not-crush requirements and had not received an order to crush the meds.
An LPN crushed and administered multiple medications labeled Do Not Crush to a resident during med pass, including an extended-release CCB, an extended-release antispasmodic, a delayed-release PPI, an antibiotic capsule, and tramadol. The resident had intact cognition and diagnoses including fractured femur, fractured humerus, COPD, and DM2, while the care plan included HTN, HLD, and a history of bradycardia. The LPN said the resident took meds better that way and had no provider order to crush them; the NP stated a provider order is required for crushing meds.
Broken narcotic lock boxes, expired medications, and unlabeled drugs were found in medication storage areas and carts. An LPN reported one narcotic lock had been broken for over two years, and multiple insulin pens and eye drop bottles on two unit carts lacked open and/or expiration dates; an expired bottle of mouthwash was also found in a medication room. The DON stated medication cart nurses were responsible for keeping medications orderly and labeling insulins and eye drops with open and expiration dates.
Food service safety standards were not followed in the main kitchen and two kitchenettes. Expired thickened cranberry juice was found in storage, the facility lacked a compatible sanitizer test kit, two of three food thermometers were out of calibration, and multiple items and areas were observed dirty or in disrepair, including a cracked wet floor sign, soiled equipment, a split refrigerator gasket, and sticky food drips in drawers and cabinets.
Pest Infestation in Main Kitchen Janitor Closet: The facility did not maintain a pest-free environment or an effective pest control program in the main kitchen. Surveyors observed small fruit flies in the janitor closet around the floor sink, and the pest control log showed the last fly treatment had been months earlier. An AD of Food Service stated the pest control vendor would be contacted about the fly issue.
Two residents with severe cognitive impairment and behavioral disturbances were not adequately supervised, resulting in one resident striking another with a walker and later being sprayed in the face with hot sauce by a different resident. Staff interviews confirmed that the need for close observation was known but not consistently implemented, leading to incidents of abuse and neglect.
Failure to implement a resident's care plan for supervision. A resident with Alzheimer's disease, dementia with behavior disturbances, and severe cognitive impairment had care plan directions for close observation and one-to-one supervision when off the unit, but was involved in multiple resident-to-resident physical abuse incidents while wandering the facility. CNAs stated the resident wandered a lot and should be closely watched, and the DON stated care plan interventions were to be implemented as written.
Garbage and refuse were not disposed of properly because the facility did not keep the dumpsters on hard, level surfaces, and one dumpster was not rodent proof. Surveyors observed that 1 of 4 dumpsters was missing a drain plug, and all four dumpsters were placed on gravel and dirt lawn instead of the surface specified on the dumpster directions. An AD of Food Service stated maintenance would be contacted about the missing drain plug and the dumpster surfaces.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect for 2 of 24 residents reviewed. One resident with diagnoses including obstructive uropathy and alcoholic cirrhosis, and whose MDS documented intact cognition and ability to understand and be understood, was observed coming out of the room for lunch and later coming out of the Activity Room with a urinary catheter bag underneath the wheelchair that was not concealed in a dignity bag and at times dragged on the floor. A CNA stated the catheter bag should have been in another bag and not dragging on the floor, and an LPN stated catheter bags should always be concealed for dignity. A second resident with diagnoses including acute kidney failure, heart failure, and COPD, and whose MDS documented intact cognition, reported being left waiting for assistance after the call light was activated and stated the roommate was assisted before them. The resident stated a CNA told another CNA that the resident was being left for last because they were slow and had taken too long in the bathroom. The resident also stated that when they requested help removing a raised toilet seat/commode setup, the CNA replied, "I'm not breaking my back to move it," and the resident had to remove it themselves in order to use the toilet. The resident further stated they urinated down their legs while waiting, that the CNA helped them to bed but did not wash them up, and that urine on the floor was not cleaned up. The DON stated the CNA admitted making the statement about saving the resident for last because they were so slow, and the CNA later attempted to recant the statement. The Administrator stated all staff were expected to treat residents with dignity and respect.
Failure to Address Significant Resident Weight Changes
Penalty
Summary
The facility did not ensure acceptable nutritional status was maintained or that nutrition care and services were provided consistent with each resident’s comprehensive assessment for three residents reviewed for nutrition and hydration status. The deficiency involved significant, unexplained weight changes that were not confirmed by reweights and were not addressed by the facility’s dietician or medical providers, despite the facility policy requiring a same-day reweigh when a resident’s weight differed by plus or minus five pounds from the prior recorded weight. One resident with paraplegia, dysphagia, acute kidney failure, and moderate cognitive impairment had a documented weight loss of 17.7 pounds between recorded weights, with no documented reweight, nutrition assessment, or provider or dietician note addressing the loss. Another resident with diabetes, COPD, and dementia had a documented weight gain of 22.5 pounds, also without documented reweight, nutrition assessment, or provider or dietician note addressing the gain. The resident’s care plan called for stabilized weight, but the record did not show follow-up on the change. A third resident with quadriplegia, diabetes, pulmonary hypertension, and moderate cognitive impairment had a documented weight loss of 35.6 pounds, and the record likewise lacked evidence of a reweight, nutrition assessment, or provider or dietician note addressing the loss. During interviews, the RD stated a reweigh should have been done for one resident on readmission and that another resident’s weight was believed to be inaccurate, while the DON stated reweights were being done but were not being entered into the computer so the RD could see them. An RN stated residents should be weighed on admission and that CNAs recorded weights while nurses entered them into the computer.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility did not provide sufficient nursing staff to meet resident needs or maintain a licensed nurse in charge on each shift as required. The facility assessment, last reviewed in July 2025, documented a bed capacity of 120 and staffing needs for a full census of 18.40 licensed nurses and 28.67 CNAs per day. On entrance to the facility, 116 residents were present on three units, and the staffing sheet showed five licensed nurses and eleven CNAs on duty. Review of staffing sheets from 08/11/2025 through 09/01/2025 showed that the facility did not meet its assessed minimum staffing on multiple shifts, including several days when the nursing schedule ranged from 11 to 18 total nurses across day, evening, and night shifts and CNA staffing ranged from 24 to 29 total aides across those shifts. During a surveyor-led resident group meeting, six residents reported that staffing was insufficient to meet their needs and that they often had to wait an extended period for care. They stated that they had been left unattended for extremely long times and that CNAs would say they would come back but never did. A CNA stated that staff were able to provide care consistently, but residents did have to wait for a more extended period at times. The Administrator stated that the facility assessment was based on full capacity and that at times the facility did not meet the assessment. The Staffing Coordinator stated staffing levels were determined by census, that the goal was to have minimum CNA coverage on each unit by shift, and that the facility was short at times but was trying to improve staffing through bonuses, bringing staff from other areas, and using a nurse training program.
Daily Nurse Staffing Information Not Posted in Accessible Location
Penalty
Summary
The facility did not post daily nurse staffing information in an area accessible to all residents and visitors as required. During observations from 08/25/2025 through 09/03/2025, the daily nurse staffing postings for each shift were located in a hallway at the far end of the building near the human resources office, which was not readily visible or accessible to all residents and visitors. Visitors of the B and C units would have had to walk to the opposite end of the building to view the staffing information, while visitors of the A unit could see it when walking by. During an interview on 09/03/2025 at 11:15 AM, Staffing Coordinator #1 stated that the staffing had always been posted in that location, that the night nursing supervisor posted the daily staffing list, and that they did not know it had to be posted in a different location.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility did not ensure that its medication error rate remained below 5 percent during medication administration observations. During the survey, 25 medication administration observations were completed, and the facility was found to have a medication error rate of 88 percent involving two residents observed during medication pass. Resident #8 had diagnoses including fractured femur, fractured humerus, COPD, and type 2 diabetes. The resident’s care plan addressed hypertension, hyperlipidemia, bradycardia, and diabetes, with interventions to give medications as ordered and monitor for side effects and effectiveness. The August 2025 MAR showed multiple 8:00 AM medications ordered to be taken whole, including diltiazem ER, ezetimibe, lactobacillus, losartan, meloxicam, montelukast, oxybutynin ER, pantoprazole DR, keflex, and aspirin. During observation on 08/28/2025 at 9:07 AM, LPN #2 crushed and administered multiple medications to Resident #8, including medications labeled do not crush such as diltiazem ER, magnesium oxide, montelukast, pantoprazole DR, oxybutynin ER, and ezetimibe. The resident’s MAR documented that medications were to be taken whole. In interview, LPN #2 stated the medications were crushed because the resident took them better that way and acknowledged being unaware that the listed medications were not to be crushed and that there was no physician order to crush them. Resident #46 had diagnoses including osteoarthritis, hypertension, and anxiety, and the MDS documented moderately impaired cognition. The August 2025 MAR listed 8:00 AM medications including metoprolol succinate ER 100 mg and 25 mg, along with other medications. During observation on 08/28/2025 at 10:15 AM, LPN #3 poured the resident’s medications into separate cups for crushed and do not crush medications, but placed metoprolol succinate ER 100 mg into the do not crush cup after being prompted that it had been placed in the crush medication cup. LPN #3 stated they were unaware that metoprolol extended-release should not be crushed and reported having been crushing it up until that time. LPN #3 also stated they had not completed the resident’s 8:00 AM medication pass because they were waiting for the resident to get dressed and out of bed, and that they were the only nurse passing medications for 40 residents on the floor.
Crushed Do Not Crush Medications Given to Resident
Penalty
Summary
The facility did not ensure residents were free from significant medication errors when an LPN crushed and administered medications that were labeled Do Not Crush for one resident during a medication administration observation. The medications observed being crushed and given were Diltiazem extended-release 120 mg, Keflex 500 mg capsule, oxybutynin extended-release 15 mg, Tramadol 50 mg, and Pantoprazole sodium delayed-release tablet. The resident had been admitted with fractured femur and fractured humerus, COPD, and type 2 diabetes, and the MDS documented intact cognition and the ability to understand and be understood. The resident’s care plan documented hypertension, hyperlipidemia, and a history of bradycardia, with interventions to give medications as ordered and observe for side effects and effectiveness. During interview, the LPN stated the medications were crushed because the resident took them better that way and was unable to provide a physician order to crush them, stating they were unaware the listed medications were not to be crushed. The NP stated a provider order was required to crush medications and that medications specifically not to be crushed would not be ordered for a resident who could not take them whole. The DON stated the facility did not currently have a nurse educator and that nurses received medication administration training upon hire.
Unsecured narcotic boxes and unlabeled medications
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional standards in five of five medication carts reviewed. During the survey, two narcotic lock boxes were found broken: on the Catskill Unit medication room narcotic box A/B, the outside lock was left ajar and an LPN stated the lock had been broken for over two years; on the Adirondack Unit medication room narcotic lockbox C/D, the outside cabinet door was not secured and was left ajar. The Catskill Unit medication room also contained a bottle of prescribed Listerine Original mouthwash for Resident #49 with an expiration date of 09/2024, and two expired medications were identified in the medication room overall. Medication carts on both units contained multiple unlabeled or improperly labeled medications. On the Catskill medication cart C/D, one Lispro, two Lantus, and one glargine insulin pens had no open and/or expiration dates, and one bottle of Refresh eye drops had an expiration date of 08/07/2025. The Catskill medication cart A/B contained one Lispro insulin pen with no open and/or expiration date. On the Adirondack medication cart A/B, one bottle of timolol eye drops and one bottle of Systane eye drops had no open and/or expiration dates. The DON stated that medication cart nurses were responsible for keeping carts clean and orderly and that all insulins and eye drops should be labeled with open and expiration dates.
Food Service Safety Deficiencies in Kitchen and Kitchenettes
Penalty
Summary
Food was not stored, prepared, distributed, or served in accordance with professional standards for food service safety in the main kitchen and two of three kitchenettes. During observation, expired thickened cranberry juice with use-by dates of 07/09/2025 and 08/12/2025 was found in the storeroom on the shelf with common stock. The facility also did not have a compatible test kit to measure the concentration of the chemical sanitizer used to manually sanitize food equipment, and the test kit on hand did not have color graduations that exceeded 400 parts per million even though the sanitizer label stated it must be diluted to between 200 and 400 parts per million. In addition, two of three food temperature thermometers were found not in calibration when tested in a standard ice-bath method, reading 38 degrees Fahrenheit and 39 degrees Fahrenheit. Several items and areas were observed to be in disrepair or soiled with food particles or grime, including a cracked and broken wet floor sign, the microwave oven, can opener and holder, knife holder, utility drawer, floor next to the door frame in the janitor closet, and wet floor signs. In the A-Unit Kitchenette, the refrigerator door gasket was split and the left-most drawer and bottom of cabinets were soiled with sticky drips of food. In the B-Unit Kitchenette, the left-most drawer was soiled with sticky drips of food.
Pest Infestation in Main Kitchen Janitor Closet
Penalty
Summary
The facility did not maintain a pest-free environment and an effective pest control program in the main kitchen. During observation on 08/25/2025 at 10:17 AM, small fruit flies were seen in the janitor closet around the floor sink. Review of the Pest Control Inspection Log dated 02/27/2025 through 07/28/2025 showed the facility was last treated for fly infestation on 02/27/2025. During an interview on 08/25/2025 at 11:06 AM, the Assistant Director of Food Service #1 stated that the pest control vendor would be contacted to address the fly issue.
Failure to Prevent Resident-to-Resident Abuse and Neglect Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents from abuse and neglect, as required by its own policies and regulatory standards. One resident with Alzheimer's disease and severe cognitive impairment was care planned to be closely observed when not in their room due to a history of behavioral issues, including wandering and aggression. Despite this, the resident was left unattended on multiple occasions, resulting in two separate incidents: in one, the resident struck another resident with their walker, and in another, the same resident was sprayed in the face with hot sauce by a different resident. Staff interviews confirmed that the resident was known to wander and required close supervision, but it was unclear whether this supervision was consistently provided. In the first incident, the resident with behavioral disturbances struck another resident, who then retaliated by hitting back. Both residents were found outside their assigned units, and staff responded by separating them. Documentation and staff interviews indicated that the resident who initiated the altercation had a pattern of striking others with their walker or running into them in the hallway. The care plan specifically called for close observation when the resident was not in their room, but this was not effectively implemented, allowing the altercation to occur. In the second incident, the same resident was found near another individual they were supposed to avoid due to a prior incident. Before staff could intervene, the other resident sprayed hot sauce into the resident's eyes. Staff responded by flushing the resident's eyes and moving them back to their unit. Interviews with staff revealed that the resident's tendency to wander and the need for close observation were well known, yet lapses in supervision allowed these incidents to happen. The facility's policy required identification and intervention in situations likely to result in abuse or neglect, but these measures were not adequately enforced.
Failure to Implement Supervision in Care Plan
Penalty
Summary
The facility did not ensure a comprehensive person-centered care plan was implemented for Resident #89, who was admitted with Alzheimer's disease, dementia with behavior disturbances, and hypertension. The resident's MDS documented severe cognitive impairment, with the resident rarely or never making themselves understood and rarely or never understanding others. The care plan identified the resident as having the potential to be physically aggressive related to anger, dementia, and poor impulse control, and another care plan directed close observation when not in the room. A separate care plan for ADL assistance stated the resident required one-to-one supervision when ambulating off the unit for safety and redirection, and the task list also documented one-to-one supervision when off the unit ambulating for safety. Despite these directions, Resident #89 was involved in multiple resident-to-resident physical abuse incidents. One incident occurred when the resident was found in another resident's room on another unit after an altercation, and staff were alerted only after the resident was heard crying out. Another incident occurred when the resident was walking in a hallway on the B unit and started hitting another resident with a walker. A third incident occurred when the resident was near another resident on another unit with whom they had a documented negative interaction before and was not separated until after an incident had occurred. CNAs stated the resident wandered the facility a lot and was supposed to be closely watched, and the DON stated that interventions on a resident's care plan were to be implemented as written.
Improper Dumpster Placement and Missing Rodent-Proof Feature
Penalty
Summary
Garbage and refuse were not disposed of properly because the facility did not ensure the dumpsters were placed on hard and level surfaces, and one of the four dumpsters was not rodent proof. During observation on 08/25/2025 at 10:50 AM, surveyors found that 1 of 4 dumpsters did not have a drain plug and was not rodent proof, and all four dumpsters were placed on gravel and dirt lawn rather than on a hard and level surface as directed on the dumpster instructions. During interview on 08/25/2025 at 11:06 AM, the Assistant Director of Food Service #1 stated they would contact maintenance regarding installation of hard level surfaces for the dumpsters and installation of the missing drain plug.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Johnsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palatine Nursing Home | 8 mi | ★★★★★ | 14 | 0 |
| Alpine Rehabilitation And Nursing Center | 9.2 mi | ★★★★★ | 16 | 0 |
| Foltsbrook Center For Nursing And Rehabilitation | 15.2 mi | ★★★★★ | 0 | 0 |
| Wells Nursing Home Inc | 15.8 mi | ★★★★★ | 1 | 0 |
| Valley Health Services Inc | 15.8 mi | ★★★★★ | 26 | 0 |
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