St. Cabrini Nursing Home

Inspectors wroteBased on observations and interviews during the abbreviated survey (2674027) the facility did not ensure that care was taken to protect the privacy of personal information to safeguard the content of the medical records from the unauthorized users. Specifically, on 1/29/2026 a surveyor observed on multiple units (unit 3 North and 2 South) medication carts unlocked and unattended with no privacy screen applied. on the computer. 1) at 10: 42am and 10:46am the surveyor observed on 3 north medication carts left unlocked and with no privacy screens applied. 2) On unit 2 south at 11:00 am and 11:03 am the surveyor observed medication carts on the unit left unattended with no privacy screen on the computer. [...]

Inspectors wroteBased on observations and interviews during the abbreviated survey (2674027) the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents. Specifically, on 1/29/2026 surveyor observed on unit 3 North 10: 42am and 10:46 am medication carts on the unit left unlocked, unattended with no privacy screen on the computer. On unit 2 south at 11:00 am and 11:03 am observed medication carts on the unit left unlocked, unattended with no privacy screen on the computer. Review of the facility's Medication Storage policy dated 12/2020 documented medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication. [...]

Inspectors wroteBased on observation, record review, and interview conducted during the recertification and abbreviated survey (NY00365065) from May 13, 2025, to May 20, 2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for Resident #489 reviewed for quality of care. Specifically, the physician was not notified timely of an 8/9/24 consultant cardiologist recommendation to reduce Carvedilol (used to treat heart failure and high blood pressure) from 25 mg to 6.25 mg. Subsequently Resident #489 continued to receive Carvedilol 25 mg until 8/13/24.

Inspectors wroteBased on record review and interviews during an abbreviated Survey (NY00325770), the facility did not ensure a resident who was incontinent of bowel received appropriate treatment and services to assure normal bowel function as possible for 1 of 3 residents reviewed for bowel care. Specifically, Resident #1's constipation care plan and the facility policy 'Bowel Protocol' were not followed. There was no documented evidence that the Physician was notified that the resident had no documented bowel movements from 08/01/2023 to 08/05/2023.

Inspectors wroteBased on observation, interview, and record review during the 5/10/23 to 5/18/23 recertification survey, the facility did not ensure all residents had the right to a dignified existence for 2 of 2 residents (Residents #153 and #43) reviewed for dignity. Specifically, (1) A Nurse was observed removing an Intravenous Therapy (IV) from the arm of Resident #153 in the dining room and (2) Resident #43 had a urinary drainage bag that was not covered and was visible from the hallway.

Inspectors wroteBased on record review, and interview conducted during the 5/10/23 to 5/18/23 Recertification Survey, the facility did not ensure that the Minimum Data Set Assessments (MDS, a resident assessment tool) accurately reflected the resident's status. Specifically, Resident #224's diagnosis of Psychosis was not documented on MDS Assessments dated 5/07/21, 8/03/21, 11/01/21, 1/28/22, 4/18/22, 7/01/22, 9/29/22, and 1/30/23. This was evident for 1 of 5 residents reviewed for Unnecessary Medications. The finding is: The facility policy and procedure titled Minimum Data Set effective date: [...]

Inspectors wroteBased on observation, record review and interview conducted during the 5/10/23 to 5/18/23 recertification survey it was determined for 1 of 1 resident (Resident #127) reviewed for range of motion/position mobility, the facility did not ensure all residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent a further decrease in range of motion. Specifically, Resident #127 required left hand resting splint as per therapy evaluations and recommendations and was observed without the resting splint in place.

Inspectors wroteBased on record review, observation, and interviews during the 5/10/23 to 5/18/23 recertification survey, the facility did not ensure residents were provided nutritional supplementation consistent with the resident's plan of care for one of two residents (Resident #135) reviewed for Nutrition. Specifically, Resident #135 did not receive their nutritional supplement as ordered by the physician.

Inspectors wroteBased on observations, interviews and record review during a recertification survey from 5/10/23 to 5/18/23, the facility did not ensure that an infection surveillance plan based on the facility assessment was implemented for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks. Specifically, infections were not being documented on the infection line list at onset of signs and symptoms of infection.

Inspectors wroteBased on record review and interview conducted during the recertification survey the facility did not ensure that care plan interventions had been evaluated for their effectiveness. Specifically, 1) care plan interventions to prevent further weight loss were not reviewed and evaluated for their effectiveness for 1 of 6 residents reviewed for nutrition (Resident #199); 2) care plan interventions were not updated to address a resident's decline in urinary status and to potentially restore bladder function, for one of two residents reviewed for urinary incontinence (Resident #31); and 3) the care plan for Resident #63 was not updated to address the resident's issue with ongoing loose stools.

Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not ensure that all employees are screened to rule out a history of abuse and neglect in accordance with its written policy. Specifically, 1 of 5 newly hired employees whose personnel records were reviewed was not screened via the Nurse Aide Registry to rule out a history of abuse/neglect of residents.

Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not ensure that the comprehensive assessment for 1 of 2 residents (Resident #276) reviewed for bladder incontinence accurately reflected the resident's bladder status. Specifically, the Minimum Data Set (MDS-a resident assessment tool) documented the resident was continent of bladder, which was not consistent with prior assessments and data collection in the resident's clinical record. This resulted in a care plan not being developed to address the resident's actual level of bladder continence.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that 1) a care plan was developed to address issues following a hospitalization, and 2) a care plan was implemented for a resident to prevent further weight loss and 3) a care plan was implemented for a resident with ongoing loose bowel movements. This was evident for 1 of 3 residents reviewed for hospitalization (Resident #187), 1 of 6 residents reviewed for nutrition (Resident #188) and 1 of 7 residents reviewed for unnecessary medications (Resident #63).

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure that residents were provided the appropriate treatment and services to improve and/or prevent a further decline in range of motion (ROM). Specifically, a resident did not have a left- hand splint applied as per Physician order. This was evident for 1 of 4 residents (#166) reviewed for positioning and limited mobility.

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey the facility did not ensure that 1)Resident #31 who was continent of bladder on admission received services and assistance to maintain continence. 2) Resident #276 received an accurate assessment of urinary status to determine the type of incontinence.

Inspectors wroteResident #63 Tube Feeding Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that the necessary care and services were provided in accordance with the physician's orders for a resident receiving a tube feeding. This was evident for 1 resident reviewed for tube feeding. (Resident #63).

Inspectors wroteBased on interview and record review conducted during the recertification survey, the facility did not ensure that a Certified Nurse Aide (CNA) demonstrated competency in dealing with a confrontational/difficult situation involving the CNA and one resident reviewed for abuse (Resident #276). Specifically, the CNA did not communicate or respond appropriately to the resident's behavior regarding a situation involving the resident's roommate in order to prevent the situation from escalating. Complaint:

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey, the facility did not ensure that the medication regimen for 1 of 7 residents (Resident #63) was adjusted to address continued use of three laxatives in the presence of adverse effects which indicated that the medications should be reduced or discontinued. Specifically, Resident #63 remained on Miralax, Colace and an enema three times weekly while experiencing multiple loose/soft BMs weekly for at least 4 months.

Inspectors wroteBased on interview and record review conducted during a recertification survey, the facility did not ensure that the right to make choices about aspects of life that were important to 1 of 3 residents reviewed for choices (#379) was provided. Specifically, the resident was not given the choice to choose between a bed bath and a shower.

Inspectors wroteBased on observation, record review, and interview conducted during a recertification survey, the facility did not ensure that care and treatment were implemented in accordance with the care plan for 1 of 3 residents (#379) reviewed for pressure ulcers. Specifically, bilateral heel boots used to offload the resident's heels were not consistently applied to promote healing and/or prevent development and/or recurrence of pressure ulcers. The finding is: Resident # 379 is a long-term care resident and was re-admitted to the facility on [DATE] with diagnoses and conditions including Stage 4 pressure ulcer to the sacral region, Cerebral Infarction, unspecified thrombosis of deep veins of the lower extremity. The Quarterly Minimum Data Set (MDS; a resident assessment tool) of 5/8/17 indicated that the resident had a BIMS of 15 out of 15 (Brief Interview for Mental Status; [...]

Inspectors wroteBased on record review, interview and observation conducted during a recertification survey, the facility did not ensure that care and treatment were implemented for 1 of 3 residents (#379) reviewed for pressure ulcers. Specifically, bilateral heel boots used to offload the resident's heels were not consistently applied to promote healing and/or prevent development of further pressure ulcers. The finding is: Resident # 379 is a long-term care resident and was re-admitted to the facility on [DATE] with diagnoses and conditions including Stage 4 pressure ulcer to the sacral region, Cerebral Infarction, unspecified thrombosis of deep veins of the lower extremity. The Quarterly Minimum Data Set (MDS; a resident assessment tool) of 5/8/17 indicated that the resident had a BIMS of 15 out of 15 (Brief Interview for Mental Status; [...]