St. Catherine of Siena Nursing and Rehabilitation C

Inspectors wroteBased on record review and interviews during the recertification survey initiated on 08/12/2025 and completed on 08/18/2025, the facility did not ensure that all comprehensive Minimum Data Set Assessments were completed within 14 calendar days after admission and not less than once every 12 months. This was identified for 10 (Residents #81, #87, #88, #100, #109, #127, #148, #291, #302, and #303) of 47 residents reviewed for the Resident Assessment Facility Task. Specifically, Residents #81, #87, #88, #100, #109, #127, #148, #291, #302, and #303's Minimum Data Set Assessments were not completed within 14 days from the assessment reference date. The finding is: The facility's policy titled Minimum Data Set (MDS) Assessment Schedule & Completion, effective Date 05/28/2025, documented each resident admitted to this facility will be assessed using the Minimum Data Set tool. [...]

Inspectors wroteBased on record review and interviews, during the recertification survey initiated on 08/12/2025 and completed on 08/18/2025, the facility did not ensure that all quarterly review Minimum Data Set Assessments were completed not less frequently than once every three (3) months. This was identified for 12 (Resident #46, #51, #54, #71, #74, #78, #82, #85, #189, #227, #235, and #285) of 47 residents reviewed for the Resident Assessment Facility Task. Specifically, Resident #46, #51, #54, #71, #74, #78, #82, #85, #189, #227, #235, and #285's Quarterly Minimum Data Set assessments were not completed within 14 days of the assessment reference date. The finding is: The facility's policy titled Minimum Data Set (MDS) Assessment Schedule & Completion, effective Date 05/28/2025, documented each resident admitted to this facility will be assessed using the Minimum Data Set tool. [...]

Inspectors wroteBased on record review and interview, during the recertification survey initiated on 08/12/2025 and completed on 08/18/2025, the facility did not ensure that all completed Minimum Data Set assessments were electronically transmitted to the Center for Medicare and Medicaid Services within 14 days of the resident assessment completion date. This was identified for 28 (Residents #303, #37, #40, #42, #46, #54, #65, #71, #78, #81, #85, #87, #89, #109, #116, #127, #157, #171, #189, #211, #215, #220, #222, #223, #235, #256, #259, and #285) of 47 residents reviewed for the Resident Assessment Facility Task. Specifically, all 28 resident assessments were not transmitted to the Center for Medicare and Medicaid Services within 14 days of the resident assessment completion date.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey initiated on 08/12/2025 and completed on 08/18/2025, the facility did not maintain accurately documented medical records on each resident that were in accordance with accepted professional standards and practices. This was identified for one (1) (Resident #46) of five (5) residents reviewed for Respiratory Care. Specifically, the facility staff mistakenly created a preset physician order in the electronic record for the Certified Nursing Assistants to check and replace the oxygen tank when the oxygen supply was low; therefore [NAME] resident who was utilizing the oxygen tank for supplemental oxygen had a physician's order for the Certified Nursing Assistants to change the oxygen tank which was not in the Certified Nursing Assistant's scope of practice. [...]

Inspectors wroteBased on observations, record review, and staff interviews during a Recertification Survey initiated on 08/12/2025 and completed on 08/18/2025, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. This was identified for one (1) (Resident #307) of eight (8) residents reviewed for the Infection Control Task. Specifically, Resident #307 tested positive for COVID-19 infection on 08/12/2025 and was placed on Droplet Precautions. Certified Nurse Assistant #4 was observed not wearing appropriate Personal Protective equipment (eye protection) while serving the resident their lunch meal in their room. [...]

Inspectors wroteBased on record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00335331) initiated on 3/14/2024 and completed on 3/22/2024 the facility did not ensure each resident was free from abuse. This was identified for two (Resident # 9 and Resident #157) of four residents reviewed for abuse. Specifically, on 3/07/2024 Certified Nursing Assistant #2 witnessed Certified Nursing Assistant #1 slap Resident #9 on their leg with an open hand and held Resident #9's wrist to the resident's mouth to prevent the resident from biting Certified Nursing Assistant #1. Immediately following this incident with Resident #9, Certified Nursing Assistant #2 witnessed Resident #157 being roughly pushed and pulled by their arms and legs by Certified Nursing Assistant #1 during care. Resident #157 complained of pain and asked Certified Nursing Assistant #1 to stop; [...]

Inspectors wroteBased on record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00335331) initiated on 3/14/2024 and completed on 3/22/2024 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. This was identified for one (Resident #157) of four residents reviewed for Abuse. Specifically, Certified Nursing Assistant #2 witnessed Certified Nursing Assistant #1 roughly handling Resident #157 during care by abruptly removing Resident #157's blanket and pulling the resident by their arms and legs while turning the resident in bed. Resident #157 complained of pain, yet Certified Nursing Assistant #1 continued to provide care. The facility did not report the allegation of abuse related to Resident #157 to the New York State Department of Health. [...]

Inspectors wroteBased on record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00335331) initiated on 3/14/2024 and completed on 3/22/2024 the facility did not initiate and complete an investigation of an alleged violation of abuse. This was identified for one (Resident #157) of four residents reviewed for Abuse. Specifically, on 3/07/2024 at approximately 6:00 AM Certified Nursing Assistant #2 observed Certified Nursing Assistant #1 abruptly removing the blanket from Resident #157 and startled the resident. Certified Nursing Assistant #1 then roughly pulled Resident # 157's arms and legs during care. The facility did not investigate the incident related to Resident #157. Cross References: F600 - Free from Abuse and Neglect F609 - Reporting of Alleged Violations The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during Recertification Survey initiated on [DATE] and completed on [DATE] the facility did not ensure each resident's Comprehensive Care Plan was reviewed and revised to reflect the current needs of the resident. This was identified for one (Resident #178) of five residents reviewed for care planning care area. Specifically, Resident #178's Comprehensive Care Plan was not updated to reflect a change in the resident's Advance Directives from a Full Code status (Cardio Pulmonary Resuscitation-CPR) to a Do Not Resuscitate (DNR) status. The finding is: The facility's policy titled, Clinical Records: Comprehensive Care Planning effective [DATE] documented the interdisciplinary care plans will be individualized to meet resident-specific needs. Resident #178 was admitted with diagnoses that included Atrial Fibrillation, Syncope and Collapse. [...]

Inspectors wroteBased on observations, record review and interviews during the Recertification Survey initiated on 5/10/2022 and completed on 5/16/2022, the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified on 3 of 4 Nursing units reviewed during the Medication Storage and Labeling Task. Specifically, 1) A Lantus insulin vial for Resident #119 was observed opened on Unit 2 A in the medication refrigerator with no date indicating when the insulin vial was first opened; 2) one Tuberculin Purified Protein Derivative (PPD) vial was observed opened and undated on the medication cart on Unit 1 B; [...]

Inspectors wroteBased on observation, record review and interviews during the Recertification Survey initiated on 5/10/2022 and completed on 5/16/2022, the facility did not ensure that each resident had a person-centered Comprehensive Care Plan (CCP) developed and implemented that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs. This was identified for one (Resident #86) of four residents reviewed for Accidents, one (Resident #98) of one resident reviewed for Communication, and one (Resident #351) of one resident reviewed for Hydration. Specifically, 1) Resident #86's Accutech Security Bracelet (a device to alert staff when a resident attempts to breech an alarmed door) was not being checked weekly for functionality as per the resident's CCP developed for wandering behavior; [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/10/2022 completed on 5/16/2022 the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (Resident #102) of 3 residents reviewed for Accidents. Specifically, Resident #102, who was identified as requiring aspiration precautions and staff assistance for eating, was observed alone in their (Resident #102) room. A lunch tray containing food items was within reach of the resident. Resident #102 was observed attempting to feed themselves for 25 minutes with no staff present. The finding is: The facility's policy titled Accident/Incident Reports (A/I) for Residents, Volunteers, and Visitors dated 6/20/2018 documented the Registered Nurse (RN)/Licensed Practical Nurse (LPN) is responsible to implement special interventions to prevent aspiration. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/10/2022 and completed on 5/16/2022, the facility did not ensure that an infection prevention and control program designed to prevent the development and transmission of infection was maintained. This was identified for one (Resident #76) of two residents reviewed for Pressure Ulcers. Specifically, during a wound care observation for Resident #76 the Licensed Practical Nurse (LPN #3) did not perform hand hygiene and change their gloves. Additionally, LPN #3 did not follow infection control practices while cleaning the Stage IV sacral pressure ulcer. The finding is: The Facility's Wound Care Dressing Change Policy and Procedure dated 1/27/2016 documented after cleansing the wound per [Physician's] order remove the gloves and place the used gloves in a plastic bag; [...]