ST CATHERINE OF SIENA NRSG AND REHAB CARE CENTER
Non profit - Corporation
240 Beds
Independent
Data: November 2025
Trust Grade
28/100
#452 of 594 in NY
Last Inspection: March 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
St. Catherine of Siena Nursing and Rehab Care Center has received a Trust Grade of F, indicating significant concerns about the facility's care standards. It ranks #452 out of 594 nursing homes in New York, placing it in the bottom half, and #36 out of 41 in Suffolk County, meaning there are only a few local options that are worse. The facility's trend is stable, with 4 issues identified in both 2022 and 2024. Staffing is a relative strength, rated 4 out of 5 stars with a low turnover rate of 29%, which is below the state average. However, the facility has concerning fines totaling $64,496, higher than 86% of New York facilities, and it provides average RN coverage. Specific incidents raised serious alarms; for instance, two residents experienced physical abuse from staff, with one being slapped and another being roughly handled despite complaining of pain. Additionally, the facility failed to properly label medications, which could lead to safety issues. While staffing appears stable and the turnover is low, the serious safety concerns and the facility's overall low grades warrant careful consideration by families seeking care for their loved ones.
- Trust Score
- F
- In New York
- #452/594
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ✓ Good
- 29% annual turnover. Excellent stability, 19 points below New York's 48% average. Staff who stay learn residents' needs.
- Penalties ⚠ Watch
- $64,496 in fines. Higher than 93% of New York facilities. Major compliance failures.
- Skilled Nurses ○ Average
- Each resident gets 37 minutes of Registered Nurse (RN) attention daily — about average for New York. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 13 deficiencies on record. Higher than average. Multiple issues found across inspections.
28/100
Bottom 24%
Review needed
4 → 4 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2022: 4 issues
2024: 4 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (29%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (29%)
19 points below New York average of 48%
Facility shows strength in staffing levels, quality measures, staff retention, fire safety.
The Bad
2-Star Overall Rating
Below New York average (3.1)
Below average - review inspection findings carefully
Federal Fines: $64,496
Above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 13 deficiencies on record
1 actual harm
Mar 2024
4 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00335331) initiated on 3/14/...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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; however, Certified Nursing Assistant #1 continued to provide care to Resident #157. This resulted in actual harm to Resident #157 that was not Immediate Jeopardy.
The finding is:
The facility's Abuse Prohibition policy dated 3/11/2023 documented that each resident has the right to be free from abuse (verbal, sexual, physical, and mental), neglect, corporal punishment, involuntary seclusion, chemical and/or physical restraints unless required to treat a medical condition, and misappropriation of personal funds or property. Acts of resident abuse, neglect, or mistreatment are not tolerated. Residents may not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Abuse Prohibition policy also included that as per the Elder Justice Act, if a reasonable suspicion of a crime has been determined either through investigation or witnessed by a covered individual, the suspicion shall be immediately reported to the Administrator, and Director of Nursing Services, Local Law enforcement, and the State Survey Agency (SA)/Department of Health.
Resident # 9 has diagnoses that include Dementia, Stroke, and Anxiety. The Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 2 which indicated the resident's cognitive skills for daily decision-making skills were severely impaired. The Minimum Data Set documented that Resident # 9 exhibited no behaviors of hitting, kicking, pushing scratching, or abusing others; and did not reject care. The Minimum Data Set documented the resident required maximum assistance of one staff member for bed mobility and transfers and moderate assistance of one person to ambulate with a rolling walker for 10 feet.
A Comprehensive Care Plan for Behavior dated 2/28/2024 documented Resident # 9 had a history of refusing treatments such as TED (compression stocking) stockings. Interventions included that staff would explain the importance of medications, meals, treatments, and care, and re-approach the resident after refusal of care.
The Incident/Accident report dated 3/07/2024 documented that at approximately 5:30 AM Certified Nursing Assistant #2 observed Certified Nursing Assistant #1 slap Resident #9 with an open hand on Resident #9's left lower calf. Certified Nursing Assistant #2 told Certified Nursing Assistant #1, Do not do that. Certified Nursing Assistant #1 responded to Certified Nursing Assistant #2, Do not tell anyone. Certified Nursing Assistant #2 reported this incident to Licensed Practical Nurse #1. Licensed Practical Nurse #1 then reported the incident to Registered Nurse Supervisor #1. Registered Nurse Supervisor #1 interviewed and assessed Resident #9. Registered Nurse Supervisor #1 documented there was no injury, bruising, redness or swelling and that Resident #9 had no recollection of the event. The Accident/Incident report documented the Nurse Practitioner was made aware.
The Nursing Progress Notes for Resident #9 were reviewed from 3/06/2024 through 3/09/2024. There was no documentation of an assessment related to the 3/07/2024 incident.
The Medical progress notes for Resident #9 were reviewed from 3/06/2024 through 3/09/2024. There was no documentation of an assessment related to the 3/07/2024 incident.
The Social Work Progress notes for Resident #9 were reviewed from 3/06/2024 through 3/09/2024. There was no documentation of the incident or an assessment of the resident.
During an interview on 3/18/2024 at 1:30 PM Certified Nursing Assistant #1 stated that on 3/07/2024, between 4:00 AM and 5:00 AM, they were asked by Certified Nursing Assistant #2 to assist with care of Resident #9. Certified Nursing Assistant #1 stated Resident #9 was fighting them. Certified Nursing Assistant #1 stated that Resident #9 raised their knee as if to kick Certified Nursing Assistant #1 near their head. Certified Nursing Assistant #1 stated on instinct they then took their hand and slapped Resident #9's knee down. Certified Nursing Assistant #1 stated that Resident #9 was then hitting them (Certified Nursing Assistant #1) on the arms so they took Resident #9's wrists and held them up to Resident #9's mouth, so Resident #9 would not try to bite them. Certified Nursing Assistant #1 stated that Resident #9 was going for a fight and was not a calm person during brief changes. Certified Nursing Assistant #1 stated, I barely hit [them (Resident #9)], it was the softest thing in the whole wide world. Certified Nursing Assistant #1 stated that they and Certified Nursing Assistant #2 continued providing care for the rest of their assigned residents. Certified Nursing Assistant #1 stated they then finished their documentation and went home. Certified Nursing Assistant #1 stated they were contacted by the Director of Nursing later that same day (3/07/2024), but they were busy and could not have a conversation. Certified Nursing Assistant #1 further stated they did not return to work at the facility because they were not happy working there and just assumed they were not on the schedule.
During an interview on 3/19/2024 at 10:30 AM Certified Nursing Assistant #2 stated they were assigned to Resident #9 and asked Certified Nursing Assistant #1 to assist them with Resident #9 because the resident can become combative during care. Certified Nursing Assistant #2 stated that they observed Certified Nursing Assistant #1 slap Resident #9 on their left leg. Certified Nursing Assistant #2 stated they yelled at Certified Nursing Assistant #1 not to do that, and Certified Nursing Assistant #1 said, do not say anything. Certified Nursing Assistant #2 stated that they looked for a nurse to report the incident upon leaving Resident #9's room but did not see a nurse. Certified Nursing Assistant #1 then asked Certified Nursing Assistant #2 to assist them with Resident #157, who was assigned to Certified Nursing Assistant #1. Certified Nursing Assistant #2 stated that Certified Nursing Assistant #1 did not knock on Resident #157's door and did not inform Resident #157 that they were going to change them. Certified Nursing Assistant #2 stated they turned on the light in Resident # 157's room and observed Certified Nursing Assistant #1 yanking blankets off of Resident #157 without warning. Certified Nursing Assistant #2 stated they observed Certified Nursing Assistant #1 using the resident's arms and legs to move them and did not use the lift pad or draw sheet. Certified Nursing Assistant #2 stated they observed Certified Nursing Assistant #1 pushing and pulling Resident #157's arms and legs roughly when they were moving Resident #157 in their bed. Certified Nursing Assistant #2 stated that Resident #157 said to Certified Nursing Assistant #1 you're hurting me and Certified Nursing Assistant #1 then said to Resident #157, well, you don't want to turn over, with an attitude and Certified Nursing Assistant #1 was pulling roughly on Resident 157's arms. Certified Nursing Assistant # 2 stated they then told Certified Nursing Assistant #1 that they would finish providing care for Resident #157. Certified Nursing Assistant #2 stated they then left Resident #157's room and told Licensed Practical Nurse #1 about what took place with both Resident #9 and Resident #157. Certified Nursing Assistant #2 stated that the next day (3/08/2024) they received a text from Certified Nursing Assistant #1 that read, [curse word] you for reporting me. Certified Nursing Assistant #2 stated they reported this to the Director of Nursing who advised Certified Nursing Assistant #2 to save the text and block Certified Nursing Assistant #1 in their phone.
Resident # 9 was not interviewed regarding the incident due to their severely impaired cognitive skills.
Review of the Accident/Incident report dated 3/07/2024 regarding Resident #9 was reviewed again on 3/19/2024 at 11:00 AM. There was no documentation in Certified Nursing Assistant #2's statements regarding Certified Nursing Assistant #1's actions that were witnessed during care to Resident #157.
Resident # 157 has diagnoses that include Morbid Obesity, Hypertension, and Major Depressive Disorder. The Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 11 which indicated the resident had moderate cognitive impairment. The Minimum Data Set Assessment documented the resident had mood symptoms of depression several (2-6) days, in a fourteen day look back period, and had no behavioral symptoms. The Minimum Data Set Assessment documented Resident #157 required maximum assistance of one person for bed mobility, maximum assistance of 2 for transfers, and ambulated with maximum assistance of one person up to 50 feet with a rolling walker.
A Comprehensive Care Plan for Mood dated 1/12/2024 documented Resident #157 had a history of Depression. Interventions included to provide emotional support, encourage the resident to express feelings, and to engage in social group activities. There were no Comprehensive Care Plan developed for behaviors or resistance to care.
The Nursing Progress Notes for Resident #157 were reviewed from 3/06/2024 through 3/09/2024. There was no documentation that an assessment of Resident #157 was conducted.
The Social Work Progress notes for Resident #157 were reviewed from 3/06/2024 through 3/09/2024. There was no documented evidence of the incident or an assessment of the resident.
During an interview on 3/19/2024 at 11:30 AM, Resident #157 stated they remember something took place, a couple of weeks ago, in the middle of the night. Resident #157 stated that two staff members came into their room, like gang busters to change their brief. Resident #157 stated one of them grabbed hold of their arm roughly to move them, and they told them, you're hurting me. Resident #157 stated Certified Nursing Assistant #1 did not care because they continued to do what they had to do. Resident #157 stated they asked Certified Nursing Assistant #2, why are they [Certified Nursing Assistant #1] doing this to me? Resident #157 stated to the surveyor, I guess they (Certified Nursing Assistant #1) were trying to tell me who was the boss. Resident #157 stated they did not tell anyone about this incident because they were afraid of retaliation. Resident #157 stated they, would be afraid if they (Certified Nursing Assistant #1) walked through that door right now.
During an interview on 3/18/2024 at 2:09 PM Licensed Practical Nurse #1 stated that on 3/07/2024 at approximately 5:00 AM - 6:00 AM, Certified Nursing Assistant #2 approached them and stated that Certified Nursing Assistant #1 was rough, and they did not want to work with Certified Nursing Assistant #1 anymore. Licensed Practical Nurse #1 stated that Certified Nursing Assistant #2 observed Certified Nursing Assistant #1 turn Resident #157 too fast and was rough. Licensed Practical Nurse #1 stated that Certified Nursing Assistant #2 told them that Certified Nursing Assistant #1, rushes the residents and did not give Resident #157 time to turn. Licensed Practical Nurse #1 stated that as they were walking away, Certified Nursing Assistant #2 stated, I didn't want to say anything but, [Resident #9] kicked [Certified Nursing Assistant #1] and [Certified Nursing Assistant #1] then slapped [Resident #9] on their leg. Certified Nursing Assistant #2 reported that Certified Nursing Assistant #1 told them, Not to say anything to the nurse. Licensed Practical Nurse #1 stated they then went to assess Resident #9 and then went to the nursing office to find and report the incidents to Registered Nursing Supervisor #1. Licensed Practical Nurse #1 stated that Registered Nursing Supervisor #1 came to the unit to assess both Resident #9 and Resident #157 between 5:30 AM and 6:00 AM.
Registered Nursing Supervisor #1 was interviewed on 3/19/2024 at 4:32 PM and stated they were working the 10:30 PM to 6:30 AM nursing shift on 3/06/2024 - 3/07/2024. Registered Nursing Supervisor #1 stated that at approximately 6:00 AM Licensed Practical Nurse #1 reported to them that Certified Nursing Assistant #2 observed Certified Nursing Assistant #1 slap Resident # 9 and abruptly pulled the blankets off Resident #157 then roughly treated Resident #157 by pulling the resident's arms and legs while turning and positioning them. Registered Nursing Supervisor #1 stated they went to the unit and performed a clinical assessment on both Resident #9 and Resident # 157.
The Director of Nursing was interviewed on 3/18/2024 at 11:30 AM and stated they received a call on the morning of 3/07/2024 from the Assistant Director of Nursing. The Assistant Director of Nursing informed the Director of Nursing that an incident had occurred that morning where Certified Nursing Assistant #1 slapped Resident #9. The Director of Nursing stated they arrived at the facility shortly after the call and immediately began to conduct an investigation. Certified Nursing Assistant #1 was placed on immediate suspension pending further investigation. The facility's security department was made aware, and a report was filed with the local Police Department. At approximately 9:00 AM - 9 :30 AM on 3/07/2024 the Director of Nursing and Assistant Director of Nursing spoke with Certified Nursing Assistant #1 over the phone to get a statement. Certified Nursing Assistant #1 stated they were busy, unable to talk, ended the call, and has been unreachable since.
The Director of Nursing and the Assistant Director of Nursing were interviewed concurrently on 3/19/2024 at 1:22 PM. Certified Nursing Assistant #2 reported that Resident #9 started to kick Certified Nursing Assistant #1 and that is when Certified Nursing Assistant #1 slapped Resident #9 on the left leg with an open hand. Certified Nursing Assistant #2 stated that they told Certified Nursing Assistant #1 not to do that and that Certified Nursing Assistant #1 told Certified Nursing Assistant #2 not to tell anyone. Certified Nursing Assistant #2 told the Director of Nursing that Certified Nursing Assistant #1 was hanging around and that they were looking for the nurse to report the incident but did not see the nurse. After the incident with Resident #9, Certified Nursing Assistant #1 was witnessed by Certified Nursing Assistant #2 roughly handling Resident #157 during care by pulling the resident's arms and legs to turn the resident. Resident #157 verbalized to Certified Nursing Assistant #1 why are you treating me like this and Certified Nursing Assistant #1 responded to Resident #157, because you won't turn. The Director of Nursing stated that Certified Nursing Assistant #2 attempted to locate a nurse after leaving Resident #9's room but did not see the nurse and was then immediately called into Resident #157's room by Certified Nursing Assistant #1. When Certified Nursing Assistant #2 left Resident #157's room they were able to locate Licensed Practical Nurse #1 and reported both incidents. The Director of Nursing stated that all staff should report any concerns related to abuse, neglect, or mistreatment immediately. The Director of Nursing stated that both residents (Resident #9 and Resident #157) were abused by Certified Nursing Assistant #1.
The Administrator was interviewed on 3/19/2024 at 3:00 PM. The Administrator stated they were made aware of alleged incidents involving Certified Nursing Assistant #1 and Residents # 9 and #157 the morning of 3/07/2024 by the Director of Nursing, and that they are involved in the Accident/Incident Investigation process. The Administrator stated it is expected that all witnessed instances of abuse must be reported immediately by all staff members. The Administrator stated that after learning further details of what occurred with Resident #157, abuse had occurred.
The Medical Director was interviewed on 3/22/2024 at 4:00 PM. The Medical Director stated they do not recall being made aware of the incidents; however, they expect that the facility would notify them or their partner of any instances where a resident may have been physically injured, in order to ensure the resident was medically assessed.
10 NYCRR 415.4(b)(1)(i)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00335331) initiated on 3/14/...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Cross References:
F600 - Free from Abuse and Neglect
F610 - Investigate/Prevent/Correct Alleged Violation
The finding is:
The Abuse Prohibition policy dated 3/11/2023 documented that investigative policies are in place for accidents, incidents, grievances, and complaints and immediate reporting of suspected or actual evidence of abuse to the Administrator, Director of Nursing Services, and Medical Director. All alleged cases of abuse, neglect, or mistreatment will be reported to the Department of Health or any other agency as appropriate by the Administrator and the Director of Nursing Services. The Abuse Prohibition policy also included that as per the Elder Justice Act, if a reasonable suspicion of a crime has been determined either through investigation or witnessed by a covered individual, the suspicion shall be immediately reported to the Administrator, and Director of Nursing Services, Local Law enforcement, and the State Survey Agency (SA)/Department of Health.
The Accident/Incident report dated 3/07/2024 documented that at approximately 5:30 AM Certified Nursing Assistant #2 observed Certified Nursing Assistant #1 slap Resident #9 with an open hand on Resident #9's left lower calf. Certified Nursing Assistant #2 told CNA #1, Do not do that. Certified Nursing Assistant #1 responded to Certified Nursing Assistant #2, Do not tell anyone. Certified Nursing Assistant #1 reported this incident to Licensed Practical Nurse #1. Licensed Practical Nurse #1 then reported the incident to Registered Nurse Supervisor #1. Registered Nurse Supervisor #1 interviewed and assessed Resident # 9. Registered Nurse Supervisor #1 documented there was no injury, bruising, redness, or swelling and that Resident #9 had no recollection of the event. The Accident/Incident report documented the Nurse Practitioner was made aware.
During an interview on 3/19/2024 at 10:30 AM Certified Nursing Assistant #2 stated they were assigned to Resident #9 and asked Certified Nursing Assistant #1 to assist them with Resident #9 because the resident can become combative during care. Certified Nursing Assistant #2 stated that they observed Certified Nursing Assistant #1 slap Resident #9 on their left leg. Certified Nursing Assistant #2 stated they yelled at Certified Nursing Assistant #1 not to do that, and Certified Nursing Assistant #1 said, do not say anything. Certified Nursing Assistant #2 stated that they looked for a nurse to report the incident upon leaving Resident #9's room but did not see a nurse. Certified Nursing Assistant #1 then asked Certified Nursing Assistant #2 to assist them with Resident #157, who was assigned to Certified Nursing Assistant #1. Certified Nursing Assistant #2 stated that Certified Nursing Assistant #1 did not knock on Resident #157's door and did not inform Resident #157 that they were going to change them. Certified Nursing Assistant #2 stated they turned on the light in Resident # 157's room and observed Certified Nursing Assistant #1 yanking blankets off of Resident #157 without warning. Certified Nursing Assistant #2 stated they observed Certified Nursing Assistant #1 using the resident's arms and legs to move them and did not use the lift pad or draw sheet. Certified Nursing Assistant #2 stated they observed Certified Nursing Assistant #1 pushing and pulling Resident #157's arms and legs roughly when they were moving Resident #157 in their bed. Certified Nursing Assistant #2 stated that Resident # 157 said to Certified Nursing Assistant #1 you're hurting me and Certified Nursing Assistant #1 then said to Resident #157, well, you don't want to turn over with an attitude and Certified Nursing Assistant #1 was pulling roughly on Resident 157's arms. Certified Nursing Assistant # 2 stated they then told Certified Nursing Assistant #1 that they would finish providing care for Resident #157. Certified Nursing Assistant #2 stated they then left Resident #157's room and told Licensed Practical Nurse #1 about what took place with both Resident #9 and Resident #157. Certified Nursing Assistant #2 stated that the next day (3/08/2024) they received a text from Certified Nursing Assistant #1 that read, [curse word] you for reporting me. Certified Nursing Assistant #2 stated they reported this to the Director of Nursing who advised Certified Nursing Assistant #2 to save the text and block Certified Nursing Assistant #1 in their phone.
Review of the Accident/Incident report dated 3/07/2024 regarding Resident #9 was reviewed again on 3/19/2024 at 11:00 AM. There was no documentation in Certified Nursing Assistant #2's statements regarding Certified Nursing Assistant #1's actions that were witnessed during care to Resident #157.
Resident # 157 has diagnoses that include Morbid Obesity, Hypertension, and Major Depressive Disorder. The Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 11 which indicated the resident had moderate cognitive impairment. The Minimum Data Set Assessment documented the resident had mood symptoms of depression several (2-6) days, in a fourteen day look back period, and had no behavioral symptoms. The Minimum Data Set Assessment documented Resident #157 required maximum assistance of one person for bed mobility, maximum assistance of 2 for transfers, and ambulated with maximum assistance of one person up to 50 feet with a rolling walker.
A Comprehensive Care Plan for Mood dated 1/12/2024 documented Resident #157 had a history of Depression. Interventions included to provide emotional support, encourage the resident to express feelings, and to engage in social group activities. There were no Comprehensive Care Plan developed for behaviors or resistance to care.
The Nursing Progress Notes for Resident #157 were reviewed from 3/06/2024 through 3/09/2024. There was no documentation that an assessment of Resident #157 was conducted.
The Social Work Progress notes for Resident #157 were reviewed from 3/06/2024 through 3/09/2024. There was no documented evidence of the incident or an assessment of the resident.
During an interview on 3/19/2024 at 11:30 AM, Resident #157 stated they remember something took place, a couple of weeks ago, in the middle of the night. Resident #157 stated that two staff members came into their room, like gang busters to change their brief. Resident #157 stated one of them grabbed hold of their arm roughly to move them, and they told them, you're hurting me. Resident #157 stated Certified Nursing Assistant #1 did not care because they continued to do what they had to do. Resident #157 stated they asked Certified Nursing Assistant #2, why are they [Certified Nursing Assistant #1] doing this to me? Resident #157 stated to the surveyor, I guess they (Certified Nursing Assistant #1) were trying to tell me who was the boss. Resident #157 stated they did not tell anyone about this incident because they were afraid of retaliation. Resident #157 stated they, would be afraid if they (Certified Nursing Assistant #1) walked through that door right now.
During an interview on 3/18/2024 at 2:09 PM Licensed Practical Nurse #1 stated that on 3/07/2024 at approximately 5:00 AM - 6:00 AM, Certified Nursing Assistant #2 approached them and stated that Certified Nursing Assistant #1 was rough, and they did not want to work with Certified Nursing Assistant #1 anymore. Licensed Practical Nurse #1 stated that Certified Nursing Assistant #2 observed Certified Nursing Assistant #1 turn Resident #157 too fast and was rough. Licensed Practical Nurse #1 stated that Certified Nursing Assistant #2 told them that Certified Nursing Assistant #1, rushes the residents and did not give Resident #157 time to turn. Licensed Practical Nurse #1 stated that as they were walking away, Certified Nursing Assistant #2 stated, I didn't want to say anything but, [Resident #9] kicked [Certified Nursing Assistant #1] and [Certified Nursing Assistant #1] then slapped [Resident #9] on their leg. Certified Nursing Assistant #2 reported that Certified Nursing Assistant #1 told them, Not to say anything to the nurse. Licensed Practical Nurse #1 stated they went to the nursing office to find and report the incidents to Registered Nursing Supervisor #1. Licensed Practical Nurse #1 stated that Registered Nursing Supervisor #1 came to the unit to assess both Resident #9 and Resident #157 between 5:30 AM and 6:00 AM.
Registered Nursing Supervisor #1 was interviewed on 3/19/2024 at 4:32 PM and stated they were working the 10:30 PM to 6:30 AM nursing shift on 3/06/2024 - 3/07/2024. Registered Nursing Supervisor #1 stated that at approximately 6:00 AM Licensed Practical Nurse #1 reported to them that Certified Nursing Assistant #2 observed Certified Nursing Assistant #1 slap Resident # 9 and abruptly pulled the blankets off Resident #157 then roughly treated Resident #157 by pulling the resident's arms and legs while turning and positioning them. Registered Nursing Supervisor #1 stated they went to the unit and performed a clinical assessment on both Resident #9 and Resident # 157. Registered Nurse Supervisor #1 stated they reported the incident to the Nursing Administration and did not initiate an investigation for Resident #157.
The Director of Nursing and the Assistant Director of Nursing were interviewed concurrently on 3/19/2024 at 1:22 PM. Certified Nursing Assistant #1 was witnessed by Certified Nursing Assistant #2 roughly handling Resident #157 during care by pulling the resident's arms and legs to turn the resident. Resident #157 verbalized to Certified Nursing Assistant #1 why are you treating me like this and Certified Nursing Assistant #1 responded to Resident #157, because you won't turn. The Director of Nursing stated they did not report the incident related to Resident #157 to the New York State Department of Health because they were not told of the arm pulling and resident's verbalization of pain.
The Administrator was interviewed on 3/19/2024 at 3:00 PM. The Administrator stated they were made aware of alleged incidents involving Certified Nursing Assistant #1 and Residents # 9 and #157 the morning of 3/07/2024 by the Director of Nursing, and that they are involved in the Accident/Incident Investigation process. The Administrator stated it is expected that all witnessed instances of abuse must be reported immediately by all staff members. The Administrator stated that after learning further details of what occurred with Resident #157, abuse had occurred. The Administrator stated they did not report the incident related to Resident #157 to the New York State Department of Health because they were not told of the arm pulling and resident's verbalization of pain.
10 NYCRR 415.4(b)(2)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00335331) initiated on 3/14/...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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:
The Abuse Prohibition policy dated 3/11/2023 documented the facility has policies and procedures in place to ensure that all accidents/incidents are fully investigated. The investigative process includes review of all accidents and incidents by designated managerial and administrative personnel. Accidents/incidents, complaints, grievances, and data collection are tracked within the facility to identify patterns and trends that may require further review and investigation, especially if they reveal potential issues of abuse. Investigative policies are in place for accidents, incidents, grievances, and complaints and immediate reporting of suspected or actual evidence of abuse to the Administrator, Director of Nursing Services, and Medical Director. Additional notifications will occur as deemed necessary through the investigative process.
Resident # 157 has diagnoses that include Morbid Obesity, Hypertension, and Major Depressive Disorder. The Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 11 which indicated the resident had moderate cognitive impairment. The Minimum Data Set Assessment documented the resident had mood symptoms of depression several (2-6) days, in a fourteen-day look back period, and had no behavioral symptoms. The Minimum Data Set Assessment documented Resident #157 required maximum assistance of one person for bed mobility, maximum assistance of 2 for transfers, and ambulated with maximum assistance of one person up to 50 feet with a rolling walker.
A Comprehensive Care Plan for Mood dated 1/12/2024 documented Resident #157 had a history of Depression. Interventions included to provide emotional support, encourage the resident to express feelings, and to engage in social group activities. There were no Comprehensive Care Plan developed for behaviors or resistance to care.
The Nursing Progress Notes for Resident #157 were reviewed from 3/06/2024 through 3/09/2024. There was no documentation that an assessment of Resident #157 was conducted.
The Social Work Progress notes for Resident #157 were reviewed from 3/06/2024 through 3/09/2024. There was no documented evidence of the incident or an assessment of the resident.
During an interview on 3/19/2024 at 10:30 AM Certified Nursing Assistant #2 stated Certified Nursing Assistant #1 asked Certified Nursing Assistant #2 to assist them with Resident #157, who was assigned to Certified Nursing Assistant #1. Certified Nursing Assistant #2 stated that Certified Nursing Assistant #1 did not knock on Resident #157's door and did not inform Resident #157 that they were going to change them. Certified Nursing Assistant #2 stated they turned on the light in Resident # 157's room and observed Certified Nursing Assistant #1 yanking blankets off of Resident #157 without warning. Certified Nursing Assistant #2 stated they observed Certified Nursing Assistant #1 using the resident's arms and legs to move them and did not use the lift pad or draw sheet. Certified Nursing Assistant #2 stated they observed Certified Nursing Assistant #1 pushing and pulling Resident #157's arms and legs roughly when they were moving Resident #157 in their bed. Certified Nursing Assistant #2 stated that Resident #157 said to Certified Nursing Assistant #1 you're hurting me and Certified Nursing Assistant #1 then said to Resident #157, well, you don't want to turn over, with an attitude and Certified Nursing Assistant #1 was pulling roughly on Resident 157's arms. Certified Nursing Assistant # 2 stated they then told Certified Nursing Assistant #1 that they would finish providing care for Resident #157. Certified Nursing Assistant #2 stated they then left Resident #157's room and told Licensed Practical Nurse #1 about what took place with both Resident #9 and Resident #157.
During an interview on 3/18/2024 at 2:09 PM Licensed Practical Nurse #1 stated that on 3/07/2024 at approximately 5:00 AM - 6:00 AM, Certified Nursing Assistant #2 approached them and stated that Certified Nursing Assistant #1 was rough, and they did not want to work with Certified Nursing Assistant #1 anymore. Licensed Practical Nurse #1 stated that Certified Nursing Assistant #2 observed Certified Nursing Assistant #1 turn Resident #157 too fast and was rough. Licensed Practical Nurse #1 stated that Certified Nursing Assistant #2 told them that Certified Nursing Assistant #1, rushes the residents and did not give Resident #157 time to turn. Licensed Practical Nurse #1 stated that as they were walking away, Certified Nursing Assistant #2 stated, I didn't want to say anything but, [Resident #9] kicked [Certified Nursing Assistant #1] and [Certified Nursing Assistant #1] then slapped [Resident #9] on their leg. Certified Nursing Assistant #2 reported that Certified Nursing Assistant #1 told them, Not to say anything to the nurse. Licensed Practical Nurse #1 stated they then went to assess Resident #9 and then went to the nursing office to find and report the incidents to Registered Nursing Supervisor #1. Licensed Practical Nurse #1 stated they returned to the unit with the Accident/Incident paperwork but tried to hide the paperwork because they did not want Certified Nursing Assistant #1 to see it. Licensed Practical Nurse #1 stated they asked Certified Nursing Assistant #2 to write a statement. Licensed Practical Nurse #1 stated that Registered Nursing Supervisor #1 came to the unit to assess both Resident #9 and Resident #157 between 5:30 AM and 6:00 AM.
Review of the Accident/Incident report dated 3/07/2024 regarding Resident #9 was reviewed again on 3/19/2024 at 11:00 AM. There was no documentation in Certified Nursing Assistant #2's statements regarding Certified Nursing Assistant #1's actions that were witnessed during care to Resident #157.
During an interview on 3/19/2024 at 11:30 AM, Resident #157 stated they remember something took place, a couple of weeks ago, in the middle of the night. Resident #157 stated that two staff members came into their room, like gang busters to change their brief. Resident #157 stated one of them grabbed hold of their arm roughly to move them, and they told them, you're hurting me. Resident #157 stated Certified Nursing Assistant #1 did not care because they continued to do what they had to do. Resident #157 stated they asked Certified Nursing Assistant #2, why are they [Certified Nursing Assistant #1] doing this to me? Resident #157 stated to the surveyor, I guess they (Certified Nursing Assistant #1) were trying to tell me who was the boss. Resident #157 stated they did not tell anyone about this incident because they were afraid of retaliation. Resident #157 stated they, would be afraid if they (Certified Nursing Assistant #1) walked through that door right now.
Registered Nursing Supervisor #1 was interviewed on 3/19/2024 at 4:32 PM and stated they were working the 10:30 PM to 6:30 AM nursing shift on 3/06/2024 - 3/07/2024. Registered Nursing Supervisor #1 stated that at approximately 6:00 AM Licensed Practical Nurse #1 reported to them that Certified Nursing Assistant #2 observed Certified Nursing Assistant #1 slap Resident # 9 and abruptly pulled the blankets off Resident #157 then roughly treated Resident #157 by pulling the resident's arms and legs while turning and positioning them. Registered Nursing Supervisor #1 stated they went to the unit and performed a clinical assessment on both Resident #9 and Resident # 157. Registered Nursing Supervisor #1 further stated that they did not initiate an investigation related to the incident with Resident #157.
The Director of Nursing and the Assistant Director of Nursing were interviewed concurrently on 3/19/2024 at 1:22 PM. Certified Nursing Assistant #2 reported that Resident #9 started to kick Certified Nursing Assistant #1 and that is when Certified Nursing Assistant #1 slapped Resident #9 on the left leg with an open hand. Certified Nursing Assistant #2 stated that they told Certified Nursing Assistant #1 not to do that and that Certified Nursing Assistant #1 told Certified Nursing Assistant #2 not to tell anyone. After the incident with Resident #9, Certified Nursing Assistant #1 was witnessed by Certified Nursing Assistant #2 roughly handling Resident #157 during care by pulling the resident's arms and legs to turn the resident. Resident #157 verbalized to Certified Nursing Assistant #1 why are you treating me like this and Certified Nursing Assistant #1 responded to Resident #157, because you won't turn. When Certified Nursing Assistant #2 left Resident #157's room they were able to locate Licensed Practical Nurse #1 and reported both incidents. The Director of Nursing stated that both residents (Resident #9 and Resident #157) were abused by Certified Nursing Assistant #1 and an investigation should have been completed for Resident #157.
10 NYCRR 415.4(b)(3)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during Recertification Survey initiated on [DATE] and completed on [DATE] th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #178's Brief Interview for Mental Status score was 12 which indicated the resident had moderately impaired cognition.
Resident #178 was observed in the dining room sitting in their (Resident#178) wheelchair on [DATE] at 2:40 PM participating in a recreational activity.
The physician's order dated [DATE] documented the resident's Code Status: Do Not Resuscitate (DNR- is a legal document a person has decided not to have Cardiopulmonary Resuscitation attempted on them if their heart or breathing stops).
The Comprehensive Care Plan for Advanced Directives dated [DATE] documented that Resident #178 was a Full code (Cardio Pulmonary Resuscitation). The care plan was updated on [DATE] to indicate the resident's Advance Directive was now Do Not Resuscitate, 21 days after the physician's order was obtained.
Registered Nurse Manager #3 was interviewed on [DATE] at 2:03 PM and stated that Resident #178's Advanced Directive status was changed to Do Not Resuscitate on [DATE]. Registered Nurse Manager #3 stated that they put the physician's order for Do Not Resuscitate in the resident's Electronic Medical Record on [DATE] and notified Social Worker #1 of the changes in the resident's Advance Directives on [DATE]. Registered Nurse Manager #3 stated Social Worker #1 was responsible for updating the Advanced Directive Care Plan.
Social Worker #1 was interviewed on [DATE] at 2:23 PM and stated that they were informed by Registered Nurse Manager #3 on [DATE] regarding Resident #178's Advanced Directive status change to Do Not Resuscitate and they (Social Worker #1) forgot to update the resident's care plan.
The Director of Nursing Services was interviewed on [DATE] at 3:44 PM and stated that the social workers were responsible for initiating and updating the Advanced Directive care plans and that Social Worker #1 should have updated Resident #178's care plan on [DATE] to reflect the accurate Advance Directive status.
10 NYCRR 415.11(c)(2)(i-iii)
May 2022
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #98 was admitted with diagnoses that include Hypertension, Anemia, and Peripheral Vascular Disease. A Quarterly Mini...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #98 was admitted with diagnoses that include Hypertension, Anemia, and Peripheral Vascular Disease. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 10, which indicated moderate cognitive impairment. The MDS documented the resident's hearing was adequate and the resident did not use a hearing device.
A Physician's order dated 9/01/2021 documented to obtain an Audiology consult for a hearing aid replacement and as needed (PRN).
An Audiology Consult dated 10/21/2021 documented the resident previously wore a left ear hearing aid which was lost.
A Review of the resident's Comprehensive Care Plan was conducted on 5/16/2022 at 12:00 PM and there was no documented evidence of a CCP developed for hearing impairment.
Resident #98 was interviewed on 5/16/2022 at 1:10 PM. The resident had difficulty hearing during the interview. The surveyor had to repeat questions and speak louder and wait for the resident to confirm that they (Resident #98) were able to hear. Resident #98 stated that the facility lost their hearing aid and replaced it with a hearing aid that was no good. Resident #98 stated when the hearing aid was inserted in their (Resident #98) ear, it felt like the hearing aid was piercing their (Resident #98) ear.
An observation of the resident's hearing aid was conducted with the Licensed Practical Nurse (LPN) #6 on 5/16/2022 at 1:20 PM. The hearing aid consisted of a small earbud and a thin plastic tube that connects the body of the hearing aid to the earbud. LPN #6 stated when the hearing aid is placed in the resident's ear, Resident #98 complained that the earbud that sits inside the ear canal was sticking them (Resident #98). LPN #6 stated that the resident previously had an old fashioned hearing aid and was not fond this new hearing aid. LPN #6 stated that the resident has been refusing to wear the hearing aid since she received the new hearing aid.
Certified Nursing Assistant (CNA) #3 was interviewed on 5/16/22 at 1:28 PM and stated that at times during care the resident had difficulty hearing them (CNA #3) and that they (CNA #3) had to repeat themselves or speak louder for the resident to hear. CNA #3 stated that the resident will let you know when they (Resident #98) were able to hear you.
Registered Nurse (RN) #4 was interviewed on 5/16/2022 at 1:40 PM and stated there was no care plan initiated for hearing impairment and that a CCP for hearing deficit should have been initiated by themselves (RN #4) or any other RN in charge.
3) Resident #351 was admitted with diagnoses that include Left Knee Joint Prosthesis Infection, Type II Diabetes Mellitus, and Hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated intact cognition. The MDS documented the resident received Intravenous (IV) medication.
The Physician's orders dated 4/22/2022 documented to:
- administer Ceftriaxone (antibiotic) 1 gram (GM) once daily until 6/17/2022 intravenously for an infection and inflammatory reaction due to unspecified internal joint prosthesis.
- provide PICC care and to change the PICC line dressing weekly. Location: Right Upper Extremity.
- monitor the PICC line every shift for placement and signs and symptoms of infiltration.
- flush the PICC line daily with 5 to 10 milliliters (ml) of saline followed by 3-5 ml Heparin flush solution when not in use.
A nursing progress note dated 4/23/2022 documented that the resident was admitted status post (Left) knee irrigation on 4/12/2022 with removal of the total knee prosthesis and the implantation of an antibiotic cemented spacer. Right Upper Extremity PICC dressing was clean, dry, and intact.
A Comprehensive Care Plan (CCP) dated 4/25/2022 documented the resident had a surgical wound to the Left Knee. The interventions included but were not limited to follow up with the surgeon as ordered, monitor wound for any evidence of infection such as redness, edema, warmth, drainage, elevated temperature, and wound care as per the Physician's orders. There was no documented evidence in the CCP for the presence or care of the PICC line.
The 3:00-11:00 PM shift Registered Nurse (RN) #6 Supervisor was interviewed on 5/13/2022 at 4:30 PM and stated that the admission nurse was responsible to complete the admission care plans and the MDS nurse or the RN Manager was responsible for initiating all the CCPs. RN #6 reviewed the medical record of Resident #98 and stated that there was no CCP developed for the use of the PICC line.
The 7:00-3:00 RN #5, Manager, was interviewed on 5/16/2022 at 10:13 AM and stated that they (RN #5) did not initiate a CCP for the PICC line. RN #5 further stated that they (RN #5) should have initiated a CCP for the PICC line and it was an oversight.
The Assistant Director of Nursing Services (ADNS) #2 was interviewed on 5/16/2022 at 10:45 AM and stated that that there should have been a CCP initiated for the PICC line or that the goals and interventions should have been added to the CCP for Antibiotic use. ADNS #2 stated that they (ADNS #2) should have identified that the CCP for the PICC line was not completed.
415.11(c)(1)
Based 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; 2) Resident #98 was identified with a left ear hearing impairment and utilized a hearing aid. There was no documented evidence that a CCP for the hearing deficit was developed; and 3) Resident #351 had a Physician's order for a right upper extremity Peripherally Inserted Central Catheter (PICC) line and there was no documented evidence that a CCP was developed for the PICC line.
The findings are:
1) The facility's policy titled Accutech System last revised on 8/15/2005 documented residents wearing an Accutech Tags (bracelet) will have the Accutech Tags tested for functionality on a weekly basis. The following information must be completed for all Tag testing: the date, time, the resident's name, and the outcome of the test by placing an x under the appropriate column: 1. alarm sounded or 2. did not sound and the nurse's signature. Tags that do not generate a sounding alarm shall be reported to the nursing supervisor and removed from the resident and a replacement Tag applied.
Resident #86 has diagnoses that include Hypothyroidism and Unspecified Dementia without Behavioral Disturbance. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required extensive physical assistance of one person for transfers, walking in their room or corridor, toilet use, personal hygiene, and bathing.
The CCP titled (Resident's name) has a history of wandering down the hallway looking to go home, last revised on 4/2/2022, documented to check the function of the Accutech Security Bracelet every week.
The Assistant Director of Nursing (ADNS) was interviewed on 5/13/2022 at 10:50 AM and stated that documentation of the function of the Accutech Security Bracelets were kept in a separate binder and not in the resident's electronic medical record (EMR). The ADNS stated that it was the responsibility of the Registered Nurse (RN), Night Supervisors, to document in the binder on a weekly basis that the Accutech Security Bracelets were functioning.
The ADNS was re-interviewed on 5/13/2022 at 12:10 PM. The ADNS returned with the Accutech binder and stated that the function of the Accutech Security Bracelets had not been checked since July of 2021. The ADNS stated that in July of 2021, the facility changed its policy regarding Accutech Security Bracelets and obtained Physician's Orders for the placement of all Accutech Security Bracelets to be checked every shift. The resident's Certified Nursing Assistant (CNA) was to check that the resident had the Accutech Security Bracelet in place and document on the Resident Care Profile, however, the CNA was not expected to check for the functionality of the bracelet. The ADNS further stated that they (ADNS) were unaware that the facility's Accutech System Policy and Procedure was never updated to reflect the changes that had taken place in July of 2021.
The full-time Night (10:30 PM to 6:30 AM) RN Supervisor was interviewed on 5/13/2022 at 2:00 PM and stated when the facility's Accutech Security Bracelet system changed in July of 2021, their understanding was that the unit nurses were signing for the Accutech placement and function every shift. The full-time Night RN Supervisor stated that in July of 2021 they stopped checking the function every week and documenting the information in the binder.
The relief Night RN Supervisor was interviewed on 5/16/2022 at 11:35 AM and stated that they only work two nights a week as the full-time Night RN Supervisor's relief. The relief Night RN Supervisor stated that in the past, they never checked the function of the Accutech Security Bracelets because the weekly checks never fell on any of the days they worked.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based 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 supervis...
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Based 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. This includes but is not limited to having the resident monitored frequently during mealtimes and providing assistance as needed, monitoring for signs and symptoms of aspiration, and communicating to members of the healthcare team the interventions planned for the patient.
Resident #102 was admitted with diagnoses including Cerebrovascular Accident (CVA), Hemiplegia and Hemiparesis, and Depression. The 4/1/2022 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS documented that the resident required one-person total assistance for eating and was on a mechanically altered diet.
A Physician's current dietary order dated 5/10/2022, effective since 11/3/2021, documented to provide a regular ground diet, aspiration precautions and no straws.
A Comprehensive Care Plan (CCP) dated 4/13/2022 titled Resident Has Been Placed on Aspiration Precautions Related to Oropharyngeal Dysphagia (difficulty swallowing) included interventions to provide diet as ordered by the Physician and aspiration precautions.
A CCP titled Activities of Daily Living (ADL) dated 4/13/2022 documented the resident required the assistance of one staff member for eating.
A CCP titled Nutritional Status dated 4/13/2022 documented the resident had a mechanically altered diet due to Dysphagia, utilized a right-angle spoon for meals, and to invite the resident to the dining room for meals.
A Rehabilitation (Rehab) Department quarterly screen dated 4/5/2022 documented the resident required extensive assistance of one staff member for eating with a right-angle spoon for all meals.
The Certified Nursing Assistant (CNA) Care Profile revised 4/13/2022 documented that the resident required one assist for eating with a right-angle spoon for all meals. There was no documentation on the CNA Care Profile that the resident was on aspiration precautions.
A Speech Language Pathology Annual Swallow Screen dated 4/25/2022 documented that oral dysphagia persists with no changes in swallowing function noted at this time. Continue ground diet with thin liquids with aspiration precautions (no straws).
A meal ticket for the 5/10/2022 lunch meal for Resident #102 documented aspiration precautions-no straws, regular-ground, and right-angled spoon.
On 5/10/2022 at 1:05 PM Resident #102 was observed in their (Resident #102) room sitting in a wheelchair with a lunch tray in front of them. The lunch tray containing the lunch meal was open, prepared and was within reach of the resident. There was no staff member present in the room. The resident was using a right-angled spoon and appeared to be having difficulty as the resident was moving the food around the plate without bringing it to their (Resident #102) mouth. During this observation the resident stated normally someone helps me. From 1:05 PM-1:30 PM no staff member came to assist or monitor the resident. At 1:30 PM most of the food remained on the resident's lunch plate. There were two liquid filled cups that were not touched.
On 5/11/2022 at 1:11 PM Resident #102 was observed in their (Resident #102) room sitting in a wheelchair. A CNA was preparing and setting up the lunch tray.
On 5/11/2022 at 1:14 PM Resident #102 was observed feeding themselves ice cream. There was no staff member in the room. The resident's prepared lunch tray was within the resident's reach.
On 5/11/2022 at 1:17 PM CNA #1 was interviewed. CNA #1, who is Resident #102's regularly assigned CNA, stated that Resident #102 feeds themselves. CNA #1 stated sometimes the staff will feed Resident #102 if the resident is sleepy, but generally the resident feeds themselves.
On 5/12/2022 at 8:50 AM Resident #102 was observed in bed being fed breakfast by CNA #2.
CNA #2 was interviewed on 5/12/2022 at 9:00 AM and stated sometimes the resident can feed themselves, but sometimes the resident does need assistance, depending on if the resident is not focusing or is tired.
Physical Therapist (PT) #1 was interviewed on 5/13/2022 at 9:25 AM and stated the resident requires extensive assistance for eating. PT #1 stated there are days when the resident can eat well and days when the resident has to be fed because the resident varies in motivation and ability.
Registered Nurse (RN) #3, who was the MDS Coordinator, was interviewed on 5/13/2022 at 9:44 AM and stated the resident cannot really use their left hand and the right hand has tremors. RN #3 stated the total assistance assessment for feeding in the MDS was based on interviews with the nurse, CNA, the resident, review of point of care documentation, and observations of the resident eating. RN #3 stated the CNA care profile does not need to specify if the resident requires extensive or total staff assistance as long as it is documented that staff assistance is needed. RN #3 stated Resident #102 is someone who needs assistance to eat.
The Assistant Director of Nursing (ADNS) was interviewed on 5/13/2022 at 10:50 AM and stated the resident fluctuates in their (Resident #102) ability to feed themselves. The ADNS stated the resident needs assistance to eat and their (Resident #102) right hand has tremors. The ADNS stated it is their (ADNS) expectation that the resident would be checked on more frequently if the meal tray was set up because the resident fluctuates in their ability to feed themselves and the resident's lunch should not be left uneaten for 25 minutes.
CNA #1 was re-interviewed on 5/13/2022 at 11:49 AM. CNA #1 stated if the resident is having trouble eating or is lethargic, we do not leave the resident alone. CNA #1 stated the resident eats pretty well by themselves and can be left alone in the room. CNA #1 stated they (CNA #1) were aware the resident was on aspiration precautions and that aspiration precautions was documented on the meal ticket.
Licensed Practical Nurse (LPN) #1 charge nurse was interviewed on 5/13/2022 at 12:13 PM and stated they (LPN #1) were aware Resident #102 was on aspiration precautions and the resident should not have been left alone in their (Resident #102) room to eat. LPN #1 stated usually if a resident is on aspiration precautions, the meal tray will not be left with the resident until the resident is ready to be fed or supervised. LPN #1 stated Resident #102 eating in their room was a carryover from the pandemic when there was no communal dining, and it has been a slow process bringing residents back to the dining room. LPN #1 stated the resident should be invited to the dining rooms for meals where the resident can be closely supervised, or fed. LPN #1 stated the meal ticket says aspiration precautions and that is how staff are made aware if a resident is on aspiration precautions.
The Speech Therapist (ST) was interviewed on 5/13/2022 at 12:15 PM and stated the resident used to have a gastrostomy tube (G tube) and had orders to receive nothing by mouth (NPO). The ST stated that the resident no longer has a G tube and is now eating ground diet meals by mouth and is on aspiration precautions. The ST stated Resident #102 requires close monitoring of every two to three minutes if eating alone in their room because of the aspiration precautions and should be encouraged to eat in the dining room.
The ADNS was re-interviewed on 5/16/2022 at 10:13 AM and stated for aspiration precautions, unless it specifically says 1 to 1 feed, the resident can be left alone in their room, but every two-to-three minutes monitoring is needed. The ADNS stated it would be impossible to provide 1 to 1 feeding to all residents who have aspiration precautions, and the ideal would be to have all residents on aspiration precautions in the dining room under supervision. The ADNS stated that aspiration precaution was documented on the meal ticket and that the facility policy did not require aspiration precautions to be documented on the CNA care profile. The ADNS stated the meal ticket identifies who is on aspiration precautions and the CNAs and nurses check the meal ticket upon distributing the meals. The ADNS stated they (ADNS) were not sure why the resident was eating meals in their (Resident #102) room and should be eating in the dining room under supervision.
RN #4 (long-term care unit manager) was interviewed on 5/16/2022 at 12:26 PM and stated Resident #102's aspiration precautions mean just no straw and does not require a one-to-one feeding assistance for eating. If the resident is left alone in their (Resident #102) room for a meal, the resident should be monitored every two to three minutes, especially if the resident needs help or is not focusing.
415.12(h)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 5/10/2022 and completed on 5/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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; then wash hands/hand hygiene and put on clean gloves.
Resident #76 has diagnoses that include a Stage IV Sacral Pressure Ulcer, Hypertension, and Non-Alzheimer's Dementia. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 3 which indicated the resident had severely impaired cognition. The MDS documented the resident had one Stage IV pressure ulcer that was not present on admission.
A Comprehensive Care Plan dated 4/13/2022 documented the resident had a Stage IV Pressure Ulcer to the sacrum. Interventions included but were not limited to administering treatment per the Physician's order.
A Physician's order dated 5/12/2022 documented to cleanse the sacral wound with normal saline and apply Promogran (wound dressing) and cover with dry protective dressing (DPD) once a day for diagnosis of the Stage IV Pressure Ulcer of the Sacral region.
A wound care observation was conducted on 5/13/2022 at 10:10 AM with LPN #3. LPN #3 was observed to wash their (LPN #3) hands and then don (put on) gloves. LPN #3 removed the soiled dressing from the sacral Stage IV wound. The dressing had a small amount of yellowish drainage. LPN #3 discarded the dressing then washed their (LPN #3) hands and donned new gloves. LPN #3 was observed to pour normal saline into the gauze packet to saturate the gauze. LPN #3 removed the gauze pads saturated with normal saline from the package and cleansed the wound. After cleansing the wound debris from the wound was observed on the gauze. LPN #3 then used the same gauze to cleanse the wound a second and third time. After cleansing the wound LPN #3 applied the Promogran wound dressing to the wound and then applied a dry protective dressing without removing their (LPN #3) gloves and washing their (LPN #3) hands.
LPN #3 was interviewed on 5/13/2022 at 10:20 AM and stated that they (LPN #3) were a new nurse and that they (LPN #3) were educated to change the gloves and perform hand hygiene after cleansing the wound. LPN #3 stated that they (LPN #3) should have removed the gloves and performed hand hygiene after cleansing the wound and before applying the Promogran wound dressing to the wound.
LPN #4, the Wound Care nurse, was interviewed on 5/13/2022 at 10:30 AM and stated that the nurses were educated to use a single gauze pad when cleaning the wound. LPN #4 stated that LPN #3 should have used a separate gauze each time they (LPN #3) cleansed the wound. LPN #4 stated that LPN #3 should have changed their (LPN #3) gloves and should have performed hand hygiene after cleansing the wound and before applying the treatment.
The Assistant Director of Nursing Service (ADNS), who was also the nurse educator, was interviewed on 5/13/2022 at 10:52 AM and stated that LPN #3 should have used a clean gauze pad each time they (LPN #3) cleansed the wound. The ADNS further stated after cleaning the wound LPN #3 should have changed their (LPN #3) gloves, performed hand hygiene, and put on clean gloves before applying the treatment to the wound.
415.19(a)(1-3), 415.19(b)(4)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based 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...
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Based 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; and 3) two multi-dose vials of PPD were observed opened in the medication refrigerator on Unit 2 B, dated February 2022 and were not discarded after the recommended 28-day period per manufacturer's specifications.
The findings are:
The facility Medication/Treatment Labeling and Storage Policy and Procedure, last revised on 2/3/2017, documented that the medications are stored according to procedures established and in compliance with federal, state and manufacturer's recommendations. The Policy further documented the expiration date is 30 days from date of opened vial for Insulin and PPD and 28 days for Lantus Insulin.
1) On 5/16/2022 at 8:16 AM, the 2A Unit medication cart and medication room were observed with Licensed Practical Nurse (LPN) # 1. One vial of Lantus insulin glargine (100 units (u)/10 milliliter (ml)) was opened and not dated for Resident #119 in the medication refrigerator. Additionally, 1 PPD vial was observed dated as opened on 2/16/2022 in the medication refrigerator.
LPN # 1 was interviewed on 5/16/2022 at 8:16 AM and stated Lantus Insulin vial should be discarded after 28 days of opening. LPN #1 was not able to state when the vial was first opened and stated that the vial had to be discarded. LPN # 1 stated the PPD vial should be discarded after 90 days.
2) During a medication storage review conducted on the 1B Unit on 5/16/2022 at 9:42 AM a PPD vial was observed on the medication cart. The PPD vial was opened and not dated.
LPN #5 was interviewed on 5/16/2022 at 9:42 AM and stated that the PPD vial should be dated when opened. LPN #5 stated it would be difficult to determine who had opened the vial. LPN #5 stated that the nurse who had opened the vial should have dated the vial.
Registered Nurse (RN) #5 was interviewed on 5/16/2022 at 10:10 AM and stated that when the PPD vial was opened, the nurse should have dated the vial and returned it to the refrigerator. RN #5 stated that the vial should be discarded 28 days after the opening date.
3) On 5/16/2022 at 10 AM, the medication room was observed on the 2B Unit with LPN #2. One PPD vial was observed opened, dated 2/8/2022, with an expiration date of June 2023. LPN #2 stated the PPD vial should be discarded as per the manufacturer's expiration date.
Pharmacist #1 was interviewed on 5/16/2022 at 10:32 AM and stated the PPD vial should be discarded after 30 days from opening. The efficacy is reduced by 10 percent after 90 days. Insulin and PPD should be dated once opened and discarded 30 days after opening and the Lantus insulin should be discarded 28 days after opening.
The Assistant Director of Nursing Services (ADNS) was interviewed on 5/16/2022 at 12:41 PM and stated that opened insulin can be stored on the cart and should be labeled with the date the vial was opened. The ADNS stated that the Lantus insulin pens and vials are usable for 28 days after opening and can be stored at room temperature. The ADNS further stated that PPD vials should be discarded after 30 days.
415.18(d)
Oct 2019
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that ea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. This was identified for 1 (Resident #316) of 25 residents reviewed for the dining observation task and 1 of 2 residents reviewed for pressure ulcers. Specifically, 1) a Certified Nursing Assistant (CNA) was observed assisting Resident #316 in the dining room for his lunch meal. The CNA was observed standing over the resident while feeding the resident. 2) Resident #176, who was sleeping in their room, had a urine collection bag that was not covered in a protective pouch. The urine collection bag could be seen outside the room.
The findings are:
1) The facility's policy and procedure dated 11/14/10 titled Feeding a Resident documented . 5) Position yourself comfortable for feeding resident , if possible, sit and maintain eye contact .
Resident #316 has diagnoses including Multidrug-Resistant Organism (MDRO), Traumatic Brain Injury (TBI), and Quadriplegia. The resident was re-admitted to the facility on [DATE]. The original admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 8 indicating the resident was moderately impaired in cognition. The MDS documented the resident required extensive assistance of one person for eating.
The Comprehensive Care Plan (CCP) developed for Activities of Daily Living (ADL) dated 10/21/19 documented the resident required one person assist for eating due to the diagnoses of TBI and Quadriplegia.
During a lunch meal dining observation on 10/22/19 at 12:50 PM, a CNA was observed standing over the resident, rather than sitting next to the resident, while assisting the resident to eat.
The Registered Nurse (RN) Unit Nurse Manager was interviewed on 10/22/19 at 1:00PM and stated that the CNA should be seated in a chair when feeding Resident #316.
The CNA who was feeding the resident was interviewed on 10/22/19 at 1:04 PM and stated that she should have been seated in a chair while assisting the resident with the meal.
2) Resident #176 has diagnoses including Depression, Paroxysmal Atrial Fibrillation, and Overactive Bladder. The resident was admitted to the facility on [DATE]. The Quarterly MDS assessment dated [DATE] documented the resident's BIMS score was 14 indicating the resident was cognitively intact for daily decision making. The MDS documented the resident had an indwelling urinary catheter.
The Physician's Order dated 1/18/19 and renewed 10/18/19 documented to utilize a Urinary Catheter French 18 with 10 millimeter (ml) balloon for diagnosis of Neurogenic Bladder.
The CCP developed for Urinary Catheter dated 10/2/19 documented the resident had an indwelling catheter secondary to Neurogenic Bladder and Overactive Bladder. Interventions included to store the urine collection bag inside a protective pouch.
On 10/24/19 at 9:00 AM and on 10/25/19 at 9:05 AM, the resident was observed in bed with the Foley catheter collection bag hanging at the resident's bedside below the level of the bladder. The urinary bag was not covered in a privacy pouch and the bag could be seen from the hallway.
The RN Unit Nurse Manager was interviewed on 10/25/19 at 9:13 AM and stated that the resident's urine collection bag should be placed inside a protective pouch for dignity.
The assigned 7:00 AM- 3:00 PM shift CNA was interviewed on 10/25/19 at 9:15 AM and stated that the resident's urinary collection bag would only be covered with a protective pouch when the resident is in the wheelchair and not when the resident is in bed.
415.3(c)(1)(i)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure that all Accidents/Incidents were thoroughly inve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure that all Accidents/Incidents were thoroughly investigated to rule out mistreatment, abuse or neglect. This was identified for 1 (Resident #154) of 2 residents reviewed for accidents. Specifically, the facility did not investigate Resident #154's injury of unknown origin within five days of the incident.
The finding is:
The facility policy for Accident/Incident Reports for Residents dated 6/20/17 documented that if there is an injury of unknown origin the investigation must include statements from all caregivers/potential witnesses going back at least 24 hours prior to the discovery of the injury in order to rule out potential abuse, mistreatment or neglect. The policy also documented that all accident or incident investigations must include information on the relationship between the accident or incident and whether there was a failure to follow the care plan.
Resident #154 was admitted to the facility on [DATE] with the diagnoses of Non-Alzheimer's Dementia, Diabetes Mellitus and Depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #154 had a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact.
The Physician's order, dated 11/9/18 and last renewed on 10/1/19, documented to check the resident's skin on bath days.
The admission Skin assessment dated [DATE] documented Resident #154 had a bruise to the left little toe.
The Nursing Progress Note dated 10/18/19 documented that Resident #154 had purplish color identified to the left pinky toe after a shower. Resident #154 complained of slight pain upon movement but refused pain medication. The toe was mobile, and the nursing supervisor was made aware.
The physician's order dated 10/19/19 documented X-Ray of the left foot related to pain in the left ankle and joints of the left foot.
The X-Ray report dated 10/19/2019 documented a deformity of the distal half of the fifth metatarsal which could be related to a chronic fracture. The report documented there was no joint dislocation.
The podiatry consult dated 10/21/19 documented that an x-ray showed chronic fracture of left 5th metatarsal. The podiatrist documented that Resident #154 reported pain and swelling in the area of the fracture, local edema, and point tenderness at 5th metatarsal head and neck. The skin at the site was documented as a resolving darkened area. The podiatrist suggested bilateral surgical shoes when out of bed for 4 weeks until symptoms resolve and an ACE wrap to the left foot. Additionally, the podiatrist suggested ice pack left foot for 10 minutes for PRN pain.
The physician's order dated 10/21/19 documented ACE wrap to left foot for 4 weeks until symptoms resolve, bilateral surgical shoes when out of bed for 4 weeks until symptoms resolve and ice pack to left 5th metatarsal for 10 min as needed.
The facility did not have a care plan addressing the chronic 5th metatarsal bone fracture as of 10/22/19.
Resident # 154 was observed watching television in her room on 10/22/19 at 9:38 AM. Resident #154 stated that she does not know why the nurse put an elastic bandage around her left ankle and that her toe was bruised. Resident #154 stated that she thought a nurse rolled over her toe with a wheelchair. She stated that she had an x-ray and they just put an elastic bandage on her today (10/22/19).
There was no Accident & Incident report initiated as of 10/23/19.
The evening shift (3 PM-11 PM) Certified Nurse Assistant (CNA) was interviewed on 10/24/19 at 3:26 PM. The CNA stated she regularly does a skin check when giving a shower and that she observed Resident #154's left pinky toe was discolored. The pinky toe appeared to be purple and bluish in color. The CNA stated that she has never seen Resident #154's toe in that condition in the past and that she reported the discoloration to the Registered Nurse on duty that shift.
The evening Registered Nurse (RN) was interviewed on 10/24/19 at 3:52 PM. The RN stated that the CNA reported to her on 10/18/19 that Resident #154 presented with discoloration to the left pinky toe. She then assessed Resident #154's skin and observed a blotchy, faded bruise with no swelling. The RN stated that she asked Resident #154 if anything had occurred that day and the resident was not sure if anything happened to her left pinky toe. The RN stated that she looked through the medical record and saw the admission skin assessment documented a discoloration on the left pinky toe. She stated that she did not initiate an Accident/Incident report because Resident #154 did not express that any incident had occurred. The RN stated that after she made her observations, she reported the finding to the evening supervisor.
The podiatrist was interviewed on 10/24/19 at 4:29 PM. The podiatrist stated that the physician referred Resident #154 for a podiatry consult following an x-ray report that documented a chronic fracture of the distal half fifth metatarsal. He stated that there was discoloration, swelling to the area and Resident #154 reported pain at the site. He stated that he has provided consultations for Resident #154 during her stay at the facility and never observed the toe in that condition. The Podiatrist stated that Resident #154 could not recall what had occurred to cause the injury. The podiatrist stated that several things could have caused the injury, including bumping her foot.
The evening RN supervisor was interviewed on 10/25/19 at 10:16 AM. The evening supervisor stated that on 10/18/19, the evening RN informed her that the CNA had given Resident #154 a shower and she was not sure where the discoloration of the toe was from. The evening supervisor reviewed the medical record and saw that Resident #154 was admitted to the facility last year with a bruise to the left pinky toe. She subsequently spoke to the patient and observed that the toe was purplish in color. She stated that Resident #154 has a diagnosis of non-thrombopenia purpura and she thought the discoloration was related to that diagnosis. She reported her conclusion to the unit nurse manager and the night shift supervisor. The RN supervisor stated that it did not occur to her to initiate an incident report or question staff who provided care for Resident #154.
The Physician's Assistant (PA) was interviewed on 10/25/19 at 11:52 AM. The PA stated that she completed the follow up on the x-ray orders on 10/21/19 and relayed the information to the Unit Manager. The medical team was informed that there was discoloration to the left pinky toe on 10/18/19 and an x-ray was ordered to rule out an acute fracture. The PA visited Resident #154 on 10/21/19 and Resident #154 could not recall if an incident had occurred. She stated she observed puffiness to the feet and purple discoloration to the left pinky toe and that a fracture could occur due to weakened bone mass. She stated that the fracture could be due to a trauma or to an everyday interaction and the PA was not aware if the staff were questioned regarding if there were any incidents that occurred.
The Unit Manager was interviewed on 10/25/19 at 12:21 PM. She stated that it was noted on the x-ray that Resident #154 had Osteopenia and the previous skin assessment documented that there was discoloration. She stated that she did not know that the skin assessment was from last year and assumed that they were referring to a current skin assessment. The Unit Manager thought that any number of things could have caused the injury. She stated that she did not initiate an investigation with staff to determine if there were any incidents across previous shifts upon discovery of the discolored toe. The Unit Manager further stated that all of the supervisors, including herself, are responsible to initiate an incident report to determine if there was mistreatment that may have caused the injury.
The Director of Nursing Services (DNS) was interviewed on 10/25/19 at 2:56 PM. The DNS stated that she was not informed of the injury until 10/23/19. She stated that in hindsight the team should have done an Accident/Incident report. The staff did not do an incident report because they concluded that it originated from a chronic condition. She stated that the resident's cognition is 13 so she is not a reliable reporter.
415.4(b)(3)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure that each resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure that each resident's Comprehensive Care Plan (CCP) was implemented with measurable objectives and time frames to meet each resident's nursing and safety needs. This was identified for one (Resident # 73) of two residents reviewed for accidents. Specifically, Resident #73's CCP for Activities of Daily Living (ADL) documented, as a safety precaution, to not provide Resident #73 with a knife. Resident # 73 was observed with a knife placed on the lunch meal tray on 10/22/19.
The finding is:
Resident #73 was admitted to the facility on [DATE] with the diagnosis of Depression, Schizophrenia and Heart Failure. The Annual Minimum Data Set (MDS) dated [DATE] documented that Resident #73 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS documented Resident #73 required supervision and set up help for eating.
The Dietary Order dated 10/18/18 documented Special Instructions: No Knife for Resident #73.
The Resident Profile dated 10/23/18 documented an Activity of Daily Living (ADL) order to supervise Resident #73 with tray set up, no knife, and offer clothing protector during meals.
The Facility Initial Psychological Evaluation dated 10/31/18 documented that Resident #73 had history of self-harm attempts, including trying to cut herself with a plastic knife.
The Annual Nutritional assessment dated [DATE] documented that the special instruction of no knife remains appropriate for Resident #73.
The ADL Care Plan dated 9/5/19 documented the intervention to supervise Resident #73 with set up and no knife allowed with meals.
Resident #73's lunch meal ticket dated 10/22/19 documented No Knife.
Resident #73 was observed on 10/22/19 at 12:48 PM eating lunch with a knife on her tray. Resident #73's meal ticket was observed to state No Knife on Tray in bold, capitalized, and highlighted letters. CNA #1, who was preparing the trays from the meal cart, was notified of the observation and removed the knife.
The Unit Manager (UM) was interviewed on 10/24/19 at 1:26 PM. After the knife was discovered on Resident #73's tray, the UM referred Resident #73 for re-evaluation by the Psychologist and to the Physician. The UM acknowledged that the current CCP was not followed. The UM stated that she held a team meeting on 10/23/19 and they reviewed the necessity of the precaution and the team determined on 10/23/19 that Resident #73 was no longer a danger to herself and should be allowed to have a knife at meals.
The Director of Nursing Services (DNS) was interviewed on 10/25/19 at 2:50 PM and stated that it is expected that all interventions are discussed during care plan meetings and that CCPs should be followed.
415.11(c)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure that all resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the recertification survey, the facility did not ensure that all residents were free of accident hazards as is possible. This was identified for one (Resident #73) of two residents reviewed for accidents. Specifically, the facility did not implement the safety precaution to keep a knife from being placed on Resident #73's tray during the mealtime observation on 10/22/19.
The finding is:
Resident #73 was admitted to the facility on [DATE] with the diagnosis of Depression, Schizophrenia and Heart Failure. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #73 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS documented Resident #73 required supervision and set up help for eating.
The Dietary Order dated 10/18/18 documented Special Instructions: No Knife for Resident #73.
The Resident Profile dated 10/23/18 documented an Activity of Daily Living (ADL) order to supervise Resident #73 with tray set up, no knife, and offer clothing protector during meals.
The Facility Initial Psychological Evaluation dated 10/31/18 documented that Resident #73 had history of self-harm attempts including trying to cut herself with a plastic knife.
The Annual Nutritional assessment dated [DATE] documented the special instruction of no knife remains appropriate for Resident #73.
The ADL Care Plan dated 9/5/19 documented the intervention to supervise Resident #73 with set up and no knife allowed with meals.
Resident #73's lunch meal ticket dated 10/22/19 documented No Knife.
Resident #73 was observed on 10/22/19 at 12:48 PM eating lunch with a knife on her tray. Resident #73's meal ticket was observed to state No Knife on Tray in bold, capitalized, and highlighted letters. CNA #1, who was preparing the trays from the meal cart, was notified of the observation and she removed the knife.
CNA #2 was interviewed on 10/22/19 at 1:20 PM. CNA #2 stated that she set up Resident #73 for lunch. She stated that she is normally assigned to set up Resident #73 at meals. She stated that Resident #73 had the precaution of no knife in place since her admission last year. CNA #2 stated that Resident #73 may have the precaution is in place to ensure her safety. She stated that today she allowed Resident #73 to independently open the utensils wrapped in a napkin and did not check to see if the knife was present. She stated that normally she stays to supervise the resident and would remove the knife immediately if she observed it on the tray.
CNA #1 was interviewed on 10/22/19 at 2:35 PM. CNA #1 stated that she was passing out the trays during lunchtime today. She stated that she was busy looking at the food items instead of the utensils. CNA #1 stated that she did not notice if the knife was removed. CNA #1 stated that the kitchen staff usually assembles the utensils and someone is responsible to remove it there. She stated that the second CNA who sets up the resident would be another check point to ensure that the knife was not in place. She stated that Resident #73 was known to be a suicide risk since her admission.
The Dietary Director was interviewed on 10/22/19 at 3:04 PM and stated that the food service worker who assembled the tray was gone for the day. The Dietary Director stated that she checks the trays prior to leaving the kitchen against the ticket. She stated that she did not observe the knife on the tray. The Dietary Director was not aware of why the removal of the knife was a precaution for Resident #73.
The Unit Manager (UM) was interviewed on 10/23/19 at 11:48 AM. The UM stated that the nursing staff should check the meal ticket for accuracy. The trays are assembled in the kitchen and the utensils are wrapped in a napkin in the kitchen. She stated once it is up, there are two additional check points to catch an error. She stated that there is a CNA passing the trays to the other CNA who then set up the residents for a meal. The final check point is the CNA who sets up the resident for the meal. The UM stated that the she discussed the error in providing Resident #73 with a knife with the CNAs involved on 10/22/19. She was informed that Resident #73 can open her own napkin and usually CNA #2 is there to supervise to ensure that a knife is not available to her.
The Food Service Worker (FSW) was interviewed on 10/24/19 at 11:15 AM. He stated that he was not paying attention when he was assembling the trays on 10/22/19 for lunch. The FSW stated that no one came to check the trays prior to sending it up. He stated that usually the CNAs check the tray before setting the residents up.
The Director of Nursing Services (DNS) was interviewed on 10/25/19 at 2:47 PM and stated that all persons touching the tray have the responsibility of checking the meal ticket to ensure precautions are followed through. It starts with the person in the kitchen assembling the tray, then the person pulling the tray from the cart set up in the kitchen, and finally the person setting up the resident for the meal.
415.12(h)(1)
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0582
(Tag F0582)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not ensure that Medicare Benefic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not ensure that Medicare Beneficiaries were issued notices when the beneficiary no longer meets the requirement for skilled care. This was identified for two of three residents selected for Beneficiary Protection Notification Review. Specifically, (Resident #367 and Resident #368) were not given notice of Medicare Non-Coverage prior to discharge.
The findings are:
1) Resident #367 was admitted to the facility on [DATE] with diagnoses including Cancer, Atrial Fibrillation and Dementia. The resident was discharged on 4/22/19. Review of the medical record revealed there was no documented evidence that a Notice of Medicare Non-Coverage was given to the resident/representative prior to discharge.
2) Resident #368 was admitted on [DATE] with diagnoses including Anemia, Multiple Sclerosis and Depression. The resident was discharged on10/19/19 . Review of the medical record revealed there was no documented evidence that a Notice of Medicare Non-Coverage was given to the resident/representative prior to discharge.
During an interview conducted on 10/24/19 at 12:24 PM with the Administrator, he stated that he did not have Medicare Non-Coverage letters for two of the three residents that were selected for Beneficiary Protection Notification Review. The Administrator stated that he did not know why the Medicare Non-Coverage letters were not given to the resident; however, a Notice of Medicare Non-Coverage letter should have been given to the resident and/or representative.
During an interview conducted on 10/24/19 at 2:49 PM with the Director of Social Service, she stated that for planned discharges the Social Workers (SW) were responsible for presenting the Medicare Non-Coverage letters to the resident and/or family if the resident was cognitively impaired. The Director of Social Service stated the letters are to be presented 48 hours prior to the discharge date . The Director of Social Service stated that they did not have a signed copy of the Medicare Non-Coverage letters; however, the discharge was coordinated with the families and they were in agreement. The Director of Social Service stated that there should have been a Medicare Non-Coverage letter given to the family to notify the family of the resident's last covered day. The Director of Social Service further stated that she was not sure if the Medicare Non-Coverage letters were reviewed with the residents or families and that there was no documentation in the progress notes that the Medicare Non-Coverage letters were reviewed with the residents and/or families.
During an interview conducted on 10/24/19 at 3:02 PM with the SW who handled the discharge for Resident #367 and Resident #368, she stated during the care plan meeting the date for discharge is determined and the Medicare Non-Coverage letter is initiated at that time. If the resident's cognition is impaired the letter is reviewed over the phone with the resident's representative. The SW stated that she did not recall reviewing the Medicare Non-Coverage letter for Resident #367, however, Resident #368 called her from her room to discuss her discharge. The SW stated that during her telephone conversation with Resident #368, she discussed discharge planning but did not initiate the Notice of Medicare Non-Coverage letter and did not present the letter to the resident signature. The SW further stated she did not recall the timeframe for presenting the Notice of Medicare Non-Coverage letters prior to discharge.
415.3(g)(2)(i)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 29% annual turnover. Excellent stability, 19 points below New York's 48% average. Staff who stay learn residents' needs.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 harm violation(s), $64,496 in fines. Review inspection reports carefully.
- • 13 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $64,496 in fines. Extremely high, among the most fined facilities in New York. Major compliance failures.
- • Grade F (28/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is St Catherine Of Siena Nrsg And Rehab's CMS Rating?
CMS assigns ST CATHERINE OF SIENA NRSG AND REHAB CARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within New York, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is St Catherine Of Siena Nrsg And Rehab Staffed?
CMS rates ST CATHERINE OF SIENA NRSG AND REHAB CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 29%, compared to the New York average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at St Catherine Of Siena Nrsg And Rehab?
State health inspectors documented 13 deficiencies at ST CATHERINE OF SIENA NRSG AND REHAB CARE CENTER during 2019 to 2024. These included: 1 that caused actual resident harm, 11 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates St Catherine Of Siena Nrsg And Rehab?
ST CATHERINE OF SIENA NRSG AND REHAB CARE CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 240 certified beds and approximately 213 residents (about 89% occupancy), it is a large facility located in SMITHTOWN, New York.
How Does St Catherine Of Siena Nrsg And Rehab Compare to Other New York Nursing Homes?
Compared to the 100 nursing homes in New York, ST CATHERINE OF SIENA NRSG AND REHAB CARE CENTER's overall rating (2 stars) is below the state average of 3.1, staff turnover (29%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting St Catherine Of Siena Nrsg And Rehab?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.
Is St Catherine Of Siena Nrsg And Rehab Safe?
Based on CMS inspection data, ST CATHERINE OF SIENA NRSG AND REHAB CARE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in New York. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at St Catherine Of Siena Nrsg And Rehab Stick Around?
Staff at ST CATHERINE OF SIENA NRSG AND REHAB CARE CENTER tend to stick around. With a turnover rate of 29%, the facility is 17 percentage points below the New York average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 27%, meaning experienced RNs are available to handle complex medical needs.
Was St Catherine Of Siena Nrsg And Rehab Ever Fined?
ST CATHERINE OF SIENA NRSG AND REHAB CARE CENTER has been fined $64,496 across 1 penalty action. This is above the New York average of $33,724. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is St Catherine Of Siena Nrsg And Rehab on Any Federal Watch List?
ST CATHERINE OF SIENA NRSG AND REHAB CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.