St. Mary's Hospital for Children

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who required respiratory care, including tracheostomy (a surgically created opening called a stoma in the front of the neck leading into the windpipe (trachea) to help a person breathe) care, received services consistent with professional standards of practice and the comprehensive person-centered care plan. This deficient practice was evidenced by the facility's nursing and respiratory therapy staff's failure to respond to critical oxygen saturation alarms for one (1) of six (6) residents (Resident #1) sampled for respiratory care. Specifically, on [DATE] at 8:58 AM, the resident's oxygen saturation dropped to 84%. A mobile alert was transmitted sequentially to Registered Nurses #1, #2, #3, and Respiratory Therapist #1. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure that alleged violations involving neglect, was reported immediately, but not later that two (2) hours after the allegation is made, if the events that caused the allegation involved or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not result in serious bodily injury, to the administrator of the facility of the facility and to other officials (including to the State Agency and adult protective services where state law provides for judications in long term care facilities). This was evident for one (1) out of six (6) residents sampled (Resident #1) for respiratory care. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain, improve, or prevent avoidable decline in range of motion and mobility. This was evident in 1 (Resident #18) of 3 residents reviewed for Limited Range of Motion, out of 25 sampled residents. Specifically, Resident #18 who had a physician's order to apply bilateral wrist cock-up splints was observed on multiple occasions without the splint applied.

Inspectors wroteBased on record review and staff interview during the recertification survey conducted from 11/8/2023 to 11/16/2023, the facility did not ensure each resident received preadmission screening for a mental disorder or intellectual disability. This was evident for 1 (Resident #99) of 27 total sampled residents. Specifically, Resident #99 did not have a Level 1 Preadmission Screening and Resident Review (PASARR) completed prior to their admission to the facility.

Inspectors wroteBased on observation, interviews, and record review conducted during an abbreviated survey (NY00303294), the facility did not ensure that a resident was free from physical abuse. This was evident for 1 of 3 residents (Resident #1) reviewed for abuse. Specifically, on 10/04/22, a Registered Nurse (RN#1) reported to the Assistant Director of Nursing (ADNS) that a Certified Nursing Assistant (CAN#1) who was assigned to resident #1 on 10/03/22 was witnessed slapping resident's arm twice while the resident was reaching out to the nebulizer treatment. In addition, the RN#1 failed to remove the accuse C.N.A#1 from patient care and allowed the C.N.A#1 to continue to work until end of shift. Resident #1 was assessed with no injury sustained from the incident.

Inspectors wroteBased on observation, interviews, and record review conducted during an abbreviated survey (NY00303294), the facility did not ensure that an alleged violation of physical abuse was reported immediately, but not later than 2 hours if the alleged violation involves abuse to the New York State Department of Health (NYSDOH). Additionally, the facility did not report the alleged violation of abuse to local law enforcement (LLE). This was evident for 1 out of 3 residents (Resident #1) reviewed for abuse. Specifically, Resident #1 was slapped twice on their right hand by Certified Nursing Assistant (CNA) #1 on 10/03/22 at approximately 08:30 PM. Registered Nurse (RN) #1 witnessed the abuse on 10/03/22 and reported it to the Assistant Director of Nursing (ADON) on 10/04/22 at 08:30 AM. The facility reported the violation of abuse to NYSDOH on 10/04/22 at 08:42 AM. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during an abbreviated survey (NY00303294), the facility did not ensure that an alleged violation of physical abuse was reported immediately, but not later than 2 hours of the alleged violation involves abuse to the New York State Department of Health (NYSDOH). This was evident for 1 of 3 residents reviewed for abuse (Resident #1). Specifically, the facility did not report the alleged allegation of abuse of resident #1 to the NYSDOH within 2 hours when the assigned Certified Nurse Assistant (C.N.A#1) was witnessed slapping resident's arm hard, twice while the resident was reaching out to the nebulizer treatment.

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00302182, NY00303936), the facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments. This was evident in 2 (Residents #2 and #3) of 3 residents reviewed for care planning. Specifically, Resident #2's and Resident #3's comprehensive care plan (CCP) for alteration in urinary elimination were not reviewed and revised at each quarterly assessment and after a change in resident condition.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00302182 and NY00303936), the facility did not ensure that residents were free from accidents. This was evident for 2 out of 3 residents (Resident #2 and #3) reviewed for accident. Specifically, 1.) Resident #2 was observed with redness to the right lower abdomen, by Certified Nursing Assistant (CNA) #3, on 09/11/22. The facility Investigation Summary dated 09/13/22 documented that Licensed Practical Nurse (LPN) #1 applied a hot compress to Resident #2's right lower abdomen to elicit elimination. LPN #1 left Resident #2's room and did not monitor the hot compress. As a result, Resident #2 sustained redness to the abdomen. Vitamin A & D Ointment was applied. Additionally, there was no Physician's Order for the use of the hot pack. [...]

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey, the facility did not ensure that residents were cared for in a manner that maintained or enhanced their dignity. Specifically, a resident's Ileostomy drainage bag and tubing were observed several times uncovered and exposed to public view in the hallway. This was evident for 1 of 1 resident reviewed for Dignity out of a sample of 28 residents (Resident #106). The finding is: The facility policy dated Colostomy/Ileostomy Care dated 10/2019 documented the following: It is the policy of the facility that the licensed nurse is responsible for the care of the resident who has an ostomy. The Policy also documented that the licensed nurse would provide stoma care while changing the ostomy pouch and provide privacy. [...]