St. Catherine of Siena

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following:On 5/26/26 at 5:25 PM, in the presence of Food Service Director (FSD) the surveyor observed the following1. The Dietary Aide (DA#1) was observed wearing with large hooped earrings in the kitchen. DA#1 stated they were not aware they could not wear large earrings in the kitchen. The FSD stated they would provide education the entire kitchen staff.2. On a 4 shelf, dish storage rack, the surveyor observed a dust-like build up on each shelf. The FSD stated the shelves would be cleaned immediately.3. [...]

Inspectors wroterepeat deficiency Based on observation, interview and review of pertinent facility documentation, the facility failed to ensure Feeding Assistance staff were assigned to feed residents that did not have complex diets (the physical/mechanical texture of the food). This deficient practice was identified for 2 of 3 residents reviewed (Resident # 17 and Resident # 28) and was evidenced by the following: 1. A review of Resident #17's admission Record face sheet (admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to; Parkinsons disease (a progressive nervous system disorder that affects movement), Epilepsy (a group of neurological disorders characterized by seizures), unspecified dementia (Loss of memory, language, problem solving that interfere with daily living) and vision loss in both eyes. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain the call bell within the resident's reach (Resident #25). This deficient practice was identified for 1 of 28 residents reviewed for accommodation of needs (Resident #25, and was evidenced by the following: On 5/28/26 at 10:10 AM, the surveyor observed Resident #25 in their bed with the call bell at the bottom of the bed, wrapped around the bed frame not within the resident's reach. The surveyor reviewed the medical record for Resident #25. A review of the admission Record reflected that the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to; chronic kidney disease, dementia, and a history of falls. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) ensure that a specialty low air loss mattress was accurately set and monitored according to the resident's weight for 1 of 3 residents (Resident #25) and b.) failed to provide a resident with a wound the necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcer development for 1 of 2 residents reviewed (Resident #4). This deficient practice was evidenced by the following:According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents and immediately after glove removal. [...]

Inspectors wroteBased on observations, interview, record review, and review of facility policies, it was determined the facility failed to provide new fall interventions following a residents fall, accurately code the Minimum Data Set ((MDS), an assessment tool used to facilitate the management of care), follow a Physician Order (PO) for residents who had a history of falls. This deficient practice was identified for 2 of 2 residents (Resident #25 and #27) reviewed for falls. The deficient practice was evidenced by the following: On [DATE] at 6:39 PM, the surveyor observed Resident #27 in bed with the eyes closed. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy it was determined that the facility failed to follow Physician Orders (PO), individualized care plan (ICP), and facility policy by not providing a privacy bag for a resident with an indwelling urinary catheter (IUC). This deficient practice was noted for 1 of 1 resident's reviewed with IUC, (Resident #6). This deficient practice was evidenced by the following:On 5/26/26 at 6:24 PM, the surveyor observed Resident #6 in bed with an IUC (flexible tube that is inserted through the urethra into the bladder to drain urine) bag observed connected to bedrail without a privacy bag. Resident#6 stated they do not recall having a privacy bag for their IUC. On 5/26/26 at 6:49 PM, the surveyor reviewed the electronic medical record (E-mar) for Resident #6. [...]

Inspectors wroteBased on observation, interview, record review and review of facility policy, it was determined that the facility failed to follow a Physician's Order (PO) for an Oxygen (O2) dependent resident and failed to include or revise the person-centered Comprehensive Care Plan (CCP) for O2 therapy, in accordance with professional standards of practice. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that all certified nursing assistants (CNA) received 12 hours of mandatory in-service training as required annually. This deficient practice was identified for 3 of 5 CNA files reviewed and was evidenced by the following:A review of the in-service records for 5 randomly selected CNAs revealed that 3 of 5 CNAs did not have the required 12 hours of annual in-service training by their anniversary date.1. CNA #1 had a hire date of 3/14/2024 and completed 11 hours, 12 minutes of training.2. CNA #2 had a hire date of 10/24/2024 and completed 6 hours of training.3. CNA #3 had a hire date of 12/5/2011 and completed 11 hours, 42 minutes of training. [...]

Inspectors wroteBased on observation, interview and review of facility provided documentation, it was determined that the facility failed to ensure that the Certified Nursing Aide (CNA) received an annual performance review for 5 of 5 CNA files reviewed. The deficient practice was evidenced by the following: On 12/27/24 at 12:08 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual performance reviews that were done for 5 randomly selected CNAs. On 12/30/24 at 9:17 AM, the LNHA stated that the facility did not have any performance reviews for the 5 CNAs. She added that the Director of Nursing (DON) had the forms that were to be used but that she had not done the reviews yet. The facility did not provide any documented evidence that the 5 CNAs received an annual performance review. [...]

Inspectors wroteBased on observation, interview and review of facility documentation, it was determined that the facility failed to ensure that a) Certified Nurses Aides (CNA) received 12 hours of mandatory in-service training for 5 of 5 CNAs reviewed (CNA #1, CNA #2, CNA #3, CNA #4 and CNA #5); and b) CNA education included abuse and resident rights for 1 of 5 CNAs reviewed (CNA #1). This deficient practice was evidenced by the following: On [DATE] at 12:08 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the annual education that was provided to 5 randomly selected CNAs. On [DATE] at 8:41 AM, the LNHA stated that the facility had a book of the education provided which were in person sessions with sign in sheets but that not everyone signed that they attended. She added that the facility did not use a computer-based education system and did not have an educator. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to notify the resident's representative and the Office of the Ombudsman in writing for an emergency transfer to the hospital. This deficient practice was identified for 1 of 1 resident, Resident #16, reviewed for hospitalization. On 12/31/24 at 8:15 AM, the surveyor observed Resident #16 during medication administration. The resident was seated in their wheelchair and was alert and oriented. A review of Resident #16's hybrid (paper and electronic) medical records revealed the following: [...]

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to provide the resident or resident representative appropriate written notification of the facility's bed hold and reserve payment policy upon transfer to the hospital for one of one residents (Resident #16) reviewed for hospitalizations. The deficient practice was evidenced by the following: On 12/31/24 at 8:15 AM, the surveyor observed Resident #16 during medication administration. The resident was seated in their wheelchair and was alert and oriented. A review of Resident #16's hybrid ( combination of paper and electronic) medical record revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set ((MDS), an assessment tool used to facilitate the management of care), in accordance with federal guidelines for 3 of 12 residents, (Resident #23, Resident #28 and Resident #17) reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 12/27/24 at 10:08 AM, the surveyor observed Resident #23 in their bed with their eyes closed. On 12/27/24 at 10:10 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) who was the nurse providing care for Resident #23. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to administer oxygen (O2) therapy according to the physician's order for 1 (one) of 2 residents (Resident #22) reviewed for respiratory care. This deficient practice was evidenced by the following: On 12/27/24 at 10:05 AM, the surveyor observed Resident #22 in bed asleep, wearing a nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) (NC) connected to an oxygen (O2) concentrator at four (4) liters per minute (lpm) on the regulator. On 12/27/24 at 10:25 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #22, which revealed the following: [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documentation, the facility failed to ensure facility staff that were utilized to assist residents that needed to be fed were appropriately trained and evaluated as competent to be a paid feeding assistant. This deficient practice was evidenced by the following: On 12/27/24 at 10:01 AM, the surveyor entered Resident #12's room. The surveyor observed a staff member (SM) wearing gloves, holding a bowl and a spoon standing next to Resident #12's bed. After the surveyor introduced herself to Resident #12, the SM put down the bowl and spoon on the tray that was on the resident's over the bed table and wiped Resident #12's mouth with a napkin. The surveyor observed that the bedside table was next to the resident's bed and it was not positioned in front of the resident for the resident to feed himself/herself. [...]

Inspectors wroteBased on interview, and record review, it was determined that the facility failed to issue the proper required Skilled Nursing Facility Beneficiary Notices for 3 of 3 residents (#10, #28, #29) reviewed for facility change notifications. The deficient practice was evidenced by the following: On 10/5/23 at 09:00 AM, the facility presented the surveyor with a list of residents who were discharged from the facility within 6 months and should have received Beneficiary Notices. The surveyor reviewed 3 of the residents (Resident #10, #28, #29) which were discharged from a Medicare Part A stay at the facility and were documented as having a discontinuation of their Medicare Part A insurance payment to the facility. Resident #10 was admitted to the facility on [DATE]. The last documented covered day of coverage for Medicare Part A service was 5/3/23. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a significant change assessment was completed for 1 of the 13 residents (Resident #1). Resident #1 was noted with more than three areas of decline with Cognitive Patterns, Mood, Behavior, Health and Skin conditions, and Nutritional Status on the 8/7/23 Quarterly (Q) MDS (Minimum Data Set), an assessment tool used to facilitate the management of care. The deficient practice was evidenced by the following: On 10/04/23 at 11:10 AM, during the initial tour, the surveyor observed the resident lying in bed, alert and awake, able to answer some of the surveyor's inquiries. The surveyor observed the tray of covered food untouched on the overbed table. Resident#1 stated he/she did not want to eat breakfast and would eat lunch instead. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately complete portions of the Minimum Data Set (MDS), an assessment tool, to accurately reflect the residents' status as of the Assessment Reference Date (ARD) for 2 of 13 residents reviewed (Resident #24 and Resident #1). The deficient practice was evidenced by the following: 1. On 10/05/23 at 11:43 AM, the surveyor interviewed the Resident #24 in the resident's room. The resident was sitting on the wheelchair. The resident stated the last time they walked was about six months ago. The resident was able to move both of their arms and legs on command. On 10/05/23 at 11:56 AM, the surveyor interviewed the Certified Nursing Assistant (CNA), who has been working at the facility for 22 years. The CNA stated to the surveyor that the resident requires a Hoyer (mechanical lift) transfer and does not walk. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to develop a comprehensive, person-centered care plan for a resident with a clinical diagnosis of depression in accordance with federal guidelines. This deficient practice was identified for 1 of the 13 residents reviewed for behavioral-emotional investigation (Resident#20). The deficient practice was evidenced by the following: On 10/05/23 at 11:14 AM, the surveyor interviewed the resident, alert with forgetfulness. Resident #20 was observed talking about the parents and becoming emotional while wiping the tears from his/her eyes. The surveyor reviewed the hybrid medical record for Resident #20. The admission Record reflected that the resident was admitted to the facility with diagnoses that included but were not limited to Depression (long-term loss of pleasure and interest). [...]

Inspectors wroteBased on observation, interview, and record review and review of pertinent facility documentation, it was determined that the facility failed to update and revise a Care Plan to include a behavior for one (1) of 13 residents, (Resident #4), reviewed for care plans. This deficient practice was evidenced by the following: On 10/4/23 at 12:03 PM, the surveyor observed in the kitchen area of the dining room a sign which read ATTENTION . Don't EVER give [Resident #4] in room [redacted] knife's with meals. On 10/4/23 at 12:18 PM, the surveyor observed Resident #4 seated in a geri-chair ( a geriatric chair that is a large padded reclining chair designed to help with limited mobility) with his/her lunch tray on an overbed table in front of the resident. The lunch tray had a pureed lunch and there was a spoon and a fork provided. The resident stated that he/she had already eaten lunch. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to follow monitoring guidelines during medication administration in accordance with acceptable standards of clinical practice. The deficient practice was identified for one (1) of two (2) nurses, who administered medications to one (1) of seven (7) residents (Resident #5) and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]