St Catherine of Siena

In the surveyor’s words

From the most serious findings on record at St Catherine of Siena, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 29, 2026

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

• No harm, potential for more than minimal, widespreadF730Jan 7, 2025

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

• No harm, potential for more than minimal, widespreadF947Jan 7, 2025

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

• No harm, potential for more than minimal, widespreadF882Oct 6, 2022

  Based on interview and facility policy review, the facility failed to ensure that the designated individual responsible for the infection control program was certified in infection prevention. This failure has the potential to affect all 23 current residents at the facility, new admissions, and the potential to have missed opportunities for prevention of the spread of the COVID-19 virus, or other infections among residents and staff. Findings include: 1. During an interview on 10/03/22 at 9:30 AM, the Administrator and Director of Nursing (DON) stated the facility did not have a specified staff member as the Infection Preventionist (IP). […]

• No harm, potential for more than minimal, patternF811May 29, 2026

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