Elizabeth Seton Children's Center

Inspectors wroteBased on observation, interview, and record review conducted during the recertification and abbreviated surveys (NY00381153/462978) from 7/31/25 to 8/7/25, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for one of two residents (Resident #119) reviewed for accidents. Specifically, staff did not perform a time out to double check if all strap eyelets were secured on the mechanical lift hooks prior to raising the lift up and Resident #119 slid out of the sling and dropped to the floor.

Inspectors wroteBased on observation, record review and interviews during the recertification survey from 7/31/25 to 8/7/25, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #72) reviewed for infection control. Specifically, Resident #72 was on contact precautions until 8/1/25 and a housekeeper was observed doing a terminal cleaning of Resident #72's room and did not use the proper personal protective equipment while removing a privacy/cubicle curtain.

Inspectors wroteBased on observations, record reviews and interviews completed during an abbreviated survey (NY00349237), the facility did not ensure that a resident received treatment and care in accordance with their comprehensive person-centered care plan. Specifically Resident #1 had a care plan in place, that documented that they required 2 staff members to provide all care. On 7/23/2024 a single Certified Nurse Aide provided care singlehandedly to Resident #1. The finding is: The facility policy titled Lifting and transferring a Child revised on 11/2024 documents that all lifting, and transfers are conducted by trained direct care staff and or clinical staff and or trained family members. It further documened that once the transfer designation is established in the care plan it must be followed at all times within the facility by all direct caregivers. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00345276) on 6/20/24, the facility did not ensure residents rights to be free from physical for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, on 6/12/24, two facility staff (Certified Nurse Aide #1 and Speech Therapist #2) witnessed an alleged staff to resident abuse involving Registered Nurse #7 and Resident #1. Registered Nurse #7 was witnessed screaming 25year olds don't behave this way-cut it out and holding Resident #1's hands down in their lap with closed hands over forearms. In an interview with Certified Nurse Aide #1 they stated they heard raised voices and saw Registered Nurse #7 loudly saying stop, are you a baby? Both witnesses did not report the incident on 6/12/24. The Speech Therapist #2 reported the incident to the administration on 6/13/24. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (NY00345276), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than two hours to the New York State Department of Health, and the results of the 5-day investigation to the New York State Department of Health in accordance with state law within 5 working days of the incident. This was identified for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, on 6/12/24, two facility staff (Certified Nurse Aide #1 and Speech Therapist) witnessed an alleged staff to resident abuse involving Registered Nurse #7 and Resident #1, which was not reported to the facility administration until 6/13/24. Certified Nurse Aide #1 did not report the incident on 6/12/24. The Speech Therapist reported the incident to the administration on 6/13/24. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00327790), the facility did not ensure that 1 of 21 sampled residents (Resident #1) was free from physical, verbal, and emotional abuse. Specifically, Certified Nurse Aide (CNA#3) witnessed CNA#1 slap Resident #1 on the face on 11/06/2023 while providing care and witnessed CNA#1 being rough in handling some of the residents in their unit. In addition, CNA#2 reported they witnessed CNA#1 being rough in handling some of the residents on their unit.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00327790), the facility did not ensure an alleged violation involving abuse was reported to the New York State Department of Health (NYS DOH) within 2 hours of occurrence. This was evident for 1 out of 21 residents (Resident #1) reviewed for abuse and mistreatment. Specifically, the facility reported a staff-to-resident abuse that occurred on 11/06/2023 to the NYSDOH on 11/09/2023.

Inspectors wroteBased upon observation, interview, and record review conducted during the recertification survey on 7/31/2023 - 8/4/2023, the facility did not ensure that foods were stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1. unwrapped, uncooked ground beef was stored in a walk-in refrigerator, 2. an unsecured chest freezer located in a hallway near the kitchen contained foods intended for consumption by residents which were not labeled with expiration dates or use by dates, and 3. A dietary staff member was observed checking food temperatures prior to meal service and did not properly sanitize the thermometer.

Inspectors wroteBased upon observation, record review, and interviews conducted during the recertification survey on 7/31/2023 - 8/4/2023, the facility did not ensure that the garbage storage area was maintained in a sanitary condition. Specifically, the ground under the loading dock located near the door to the trash compactor was heavily littered with solid debris including two (2) treatment items labeled with personal health information.

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, the facility did not ensure that food brought in from the outside was handled according to professional standards of practice. Specifically, food items found in the refrigerators on resident units were either outdated or not labeled and dated. This was evident on 2 of 8 resident units ([NAME] Park and [NAME] Park).

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure that the Ombudsman was being notified of resident transfers. This was evident for 2 residents reviewed for hospitalization (Resident #19 and #156).