Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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. Joseph's Hospital - Skilled Nursing Facility during CMS and state inspections, most recent first.
The facility failed to maintain functional automatic door accessibility pads at the main entrance, resulting in non-operational exterior and interior door-opening switches that required manual door operation. A resident with polyneuropathy and osteoarthritis who used a wheelchair reported the pads had not worked for months and that family members had to hold the heavy doors open. Another wheelchair user with bilateral lower-extremity amputations described needing to call or flag down security or attract attention inside to re-enter. A third resident with traumatic brain injury and epilepsy stated the entrance pads had not worked for some time and did not attempt to use them. Despite a policy requiring work orders for malfunctioning equipment, no related work orders were found, and both the Administrator and Director of Facilities were unaware the pads were not functioning.
A resident with polyneuropathy and osteoarthritis, who used a manual wheelchair and was cognitively intact, sustained bruising and swelling to the left wrist and forearm after an elevator door closed on the arm. Nursing progress notes and an orthopedic visit documented the injury, but no incident report was completed, no investigation or root cause analysis was initiated, and no Safety Committee review or work order for the elevator was generated. Facility leaders, including an RN manager, the DON, and the Director of Facilities, confirmed that required documentation and investigation related to the elevator incident were not completed, in violation of facility policies for accident and equipment-related incident investigation.
The facility failed to ensure an elevator remained free of accident hazards and did not adequately investigate or address known door-closing issues. A resident with neuropathy and osteoarthritis, who self-propelled in a wheelchair, had an arm caught when trying to stop the elevator door, resulting in bruising and pain, with no incident report completed by the DON. Another wheelchair-dependent resident with bilateral leg amputations was observed having the elevator door close on the wheelchair and using an arm to stop it. Staff and residents reported that this elevator’s doors close too quickly and do not reliably reopen, and leadership acknowledged awareness of the problem, yet there was no maintenance work order or documented testing or repair of the door sensor or closing mechanism despite prior inspection violations.
The facility failed to complete baseline care plans within 48 hours of admission for several residents, as required by policy. For some residents, there was no documented evidence of completed care plans, and for others, no summary was provided to residents or their representatives. Staff interviews revealed issues with the electronic health system and insufficient training for newer staff.
The facility failed to comply with the 2015 International Fire Code and NFPA 720 standards by not maintaining proper documentation and monthly testing of carbon monoxide detectors. Observations revealed detectors in the Energy Center and main kitchen, but the Facilities Manager admitted to not conducting required monthly tests.
The facility did not ensure nurse staffing information was posted with required details and accessibility. Observations showed the postings lacked accurate numbers and total hours worked by nursing staff, and were only accessible on one floor. Interviews revealed unawareness of requirements and limited posting locations.
Failure to Maintain Functional Automatic Door Accessibility at Main Entrance
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, comfortable, and accessible main entrance by not ensuring the functionality of the automatic door accessibility pads. The facility had a policy requiring completion of a work order when equipment malfunctioned, but no work orders were found related to the entrance accessibility pads. During observations on two separate days, the surveyor pressed both the exterior and interior automatic door opening pads at the main entrance and the automatic doors did not open, requiring manual operation. The Administrator and the Director of Facilities both stated they were not aware that the entrance accessibility pads were not functioning. Multiple residents who used wheelchairs reported that the entrance accessibility pads had not worked for an extended period and described their experiences accessing the building. One resident with polyneuropathy and osteoarthritis, who was cognitively intact and used a wheelchair for mobility with staff supervision, stated the front entrance handicap pads had not worked since the previous summer and that family members had to hold the heavy doors open to allow exit. Another cognitively intact resident with left above-the-knee and right below-the-knee amputations, who independently self-propelled a wheelchair, reported that when returning to the facility, they had to call or flag down security or get someone’s attention inside for assistance to re-enter because the entrance switch did not work. A third resident with traumatic brain injury, epilepsy, and moderately impaired cognition stated the outside entrance accessibility pads had not worked in a while and did not attempt to use them.
Failure to Investigate and Document Elevator-Related Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to investigate and document an alleged neglect incident in which a resident was injured by an elevator door. Facility policies required that all accidents and incidents be investigated by the department director, that serious accidents or unusual frequencies of accidents be investigated by the Safety Committee, and that an incident report be prepared when equipment was involved in an injury. The resident had diagnoses including polyneuropathy and osteoarthritis, was cognitively intact, and used a manual wheelchair for mobility. Progress notes documented that the resident bumped their left arm on the elevator doors and later reported left wrist and forearm pain after the elevator door closed on their arm, with observed bruising and slight swelling. An orthopedic evaluation found no acute bony abnormality and recommended conservative management. Despite these documented injuries and the involvement of elevator equipment, the facility did not complete an incident report, initiate an investigation, or conduct a root cause analysis. The Director of Facilities reported no work order was received related to the elevator closing on the resident’s arm. The RN Manager stated that after the incident the focus was on caring for the resident and notifying administration, and confirmed that an incident report was not completed. The DON stated that an incident report and investigation report related to the elevator injury could not be located and were not completed. Facility documentation showed no evidence that an investigation was initiated, no root cause analysis was conducted, and no Safety Committee review occurred following the incident, contrary to facility policy and regulatory requirements.
Failure to Address Hazardous Elevator Door Leading to Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to maintain the resident environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents, specifically related to [NAME] Elevator #5. One resident with polyneuropathy and osteoarthritis, cognitively intact and using a manual wheelchair with staff-supervised self-propulsion, had their arm caught when attempting to stop the elevator door from closing. Nursing progress notes documented that the resident bumped their left arm on the elevator doors and later reported left wrist and forearm pain, with bruising and slight swelling, leading to an orthopedic evaluation that showed no fracture and recommended conservative management. The resident and a sitter both reported that the elevator door did not stop or reopen when the arm was placed across the doorway, and the sitter stated the door had been closing in this manner for approximately five years. Despite this incident, the DON reported that no incident report could be located or had been completed, and there was no documented investigation of the elevator’s door sensor or closing mechanism. A second cognitively intact resident with bilateral lower extremity amputations, who independently navigated the facility in a manual wheelchair, was observed entering [NAME] Elevator #5 when the door closed on the wheelchair, requiring the resident to use an arm to stop the door and reposition the chair. This resident and a CNA both stated that the elevator doors close too quickly, with staff avoiding placing arms in the doorway because the doors will close quickly and “slam shut,” and the resident reporting sometimes needing to stop the doors manually with hands. The Administrator acknowledged awareness that [NAME] Elevator #5 closed quicker than the other elevator and that a resident’s arm had been pinched when attempting to stop the door. The Director of Facilities stated elevators are inspected yearly and not routinely checked, with work orders completed only when problems are reported, and maintenance documentation contained no work order for a door malfunction on this elevator. Multiple prior inspection reports identified violations for [NAME] Elevator #5, and there was no documented evidence that the door sensor or closing mechanism had been tested or repaired following the first resident’s injury.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for several residents, as required by their policy. Specifically, for four residents, there was no documented evidence that a baseline care plan was completed within the required timeframe. Additionally, for three other residents, there was no evidence that a summary of the baseline care plan was provided to the residents or their representatives. This deficiency was identified during a recertification survey conducted from July 22 to July 26, 2024. The report highlights specific cases, such as a resident with breast cancer and anxiety, and another with severe cognitive impairment, where the facility did not provide the necessary documentation of baseline care plans. Interviews with staff revealed that the electronic health system used by the facility did not adequately prompt nurses to complete these plans, and newer staff may not have received sufficient training. The Director of Nursing acknowledged the oversight and the lack of clarity in the electronic system regarding the completion of baseline care plans.
Non-Compliance with Carbon Monoxide Detection Standards
Penalty
Summary
The facility was found to be non-compliant with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which mandates the use of carbon monoxide detection in buildings with fuel-burning appliances. During the Recertification Survey, it was observed that a carbon monoxide detector was installed on the wall in the Energy Center housing a 500-Kilowatt generator. However, the facility failed to provide documentation of the locations of all carbon monoxide detectors within the facility and did not maintain records of monthly inspections and testing of these detectors, as required by the 2012 Edition of NFPA 720. In an interview, the Facilities Manager admitted to the surveyor that the facility was likely not conducting the required monthly tests of the carbon monoxide detectors. Additionally, a carbon monoxide detector was observed on the wall outside the staff dining area in the main kitchen, which contains a natural gas range. The lack of proper documentation and testing of carbon monoxide detectors indicates a failure to comply with the necessary safety standards, posing potential risks to the safety of the facility's environment.
Inadequate Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted with the required details and in a location accessible to all residents and visitors. Observations during the survey revealed that the nurse staffing information did not consistently include the accurate number and total hours worked by both licensed and unlicensed nursing staff. Additionally, the staffing information was only posted on the third-floor residential care unit, which was not accessible to residents or visitors on the fifth floor without staff assistance. This lack of accessibility and incomplete information was confirmed through interviews with the Director of Nursing and Scheduler #1, who were unaware of the requirement to include total hours worked by each discipline on the postings. The review of daily nursing information from June 1 to July 24 showed multiple days where the accurate number of Registered Nurses was not included, particularly excluding Registered Nurse Supervisors. Scheduler #1, responsible for completing and posting the daily nursing staffing information, admitted to not being aware of the requirement to include total hours worked and confirmed that the information was only posted in one location. The Director of Nursing acknowledged the requirement for both the number of each nursing discipline and the total hours worked to be included in the postings but was unsure why the information was only posted on one unit.
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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.
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Nursing homes near Elmira
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chemung County Health Center - Nursing Facility | 0.1 mi | ★★★★★ | 0 | 0 |
| Elcor Nursing And Rehabilitation Center | 5.7 mi | ★★★★★ | 6 | 0 |
| Bethany Nursing Home & Health Related Facility Inc | 7.1 mi | ★★★★★ | 0 | 0 |
| Corning Center For Rehabilitation And Healthcare | 13.2 mi | ★★★★★ | 0 | 0 |
| Sayre Health Care Center | 13.5 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.