Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Catherine Of Siena during CMS and state inspections, most recent first.
Kitchen sanitation practices were not maintained in accordance with facility policy. A Dietary Aide wore large hooped earrings in the kitchen despite the uniform policy prohibiting jewelry, and the surveyor observed dust-like buildup on dish storage shelves, burnt-on food-like particles and grease on the stovetop griddle, dust on walk-in refrigerator fan covers, and a dry storage room temperature of 80F, above the facility’s stated range.
Feeding assistant staff were assigned to residents who were not appropriate for the program because they had complex diets and swallowing issues. One resident had Parkinson’s disease, severe cognitive impairment, and a mechanical soft diet, while another had dementia, severe cognitive impairment, dysphagia, and a pureed diet with instructions to be fed only when adequately alert. The DON acknowledged the safety concern, and facility policy stated feeding assistants may only assist residents without complicated feeding problems.
A resident with dementia, CKD, and a history of falls was observed in bed with the call bell at the bottom of the bed, wrapped around the bed frame and not within reach. The resident’s MDS showed severe cognitive impairment and need for staff help with ADLs, and the care plan directed staff to keep the call light within reach. The RN, DON, and CNA acknowledged the call bell should have been within the resident’s reach.
A resident with a specialty air mattress had the pump set at 250 lbs. even though the resident weighed 143.8 lbs., despite an order to verify the correct weight setting. In a separate observation, an RN provided wound care to a resident with DM and CHF using an uncleaned over-bed table, improper hand hygiene technique, and wrote on the dressing after it was applied rather than labeling it beforehand.
Failure to update fall interventions and follow a PO for fall precautions: one resident with dementia, Parkinson’s disease, and a history of falls had a fall that was not coded on the quarterly MDS and the care plan was not updated with new interventions after the fall; another resident with dementia and a history of falls had a PO for a floor mat on the left side of the bed, but the mat was observed folded against the wall instead of in place.
A resident with an indwelling urinary catheter was observed in bed with the drainage bag attached to the bedrail and not covered by a privacy bag, despite a PO and ICP directing that catheter supplies not be left in view and that the bag always be covered. A later observation found the bag uncovered again, and an LPN could not explain why the resident did not have a privacy bag as required by facility policy.
A resident with severe cognitive impairment and oxygen dependence had conflicting oxygen orders, and staff observed the oxygen flow set below the amount stated by an LPN. The e-MAR/e-TAR did not reflect all oxygen orders or document O2 saturation readings, and the CCP did not include a separate focus for oxygen therapy, despite the DON stating it should have been clear and aligned with the hospice plan.
The facility failed to ensure that all CNAs completed the required 12 hours of annual in-service training by their anniversary date. Record review showed that 3 of 5 CNAs reviewed did not meet the yearly training requirement, and the IP/Staff Educator, LNHA, and DON acknowledged the shortfall. The facility policy required yearly CNA in-service training.
The facility failed to conduct annual performance reviews for CNAs, as required by their policy. The LNHA and DON admitted that no reviews had been completed for five CNAs, despite the policy mandating annual evaluations to provide feedback and address performance issues. The DON had not conducted any reviews during her seven-month tenure, leading to a deficiency finding.
The facility failed to provide the required 12 hours of in-service training for all CNAs reviewed, with one CNA missing mandatory training in abuse prevention and resident rights. The LNHA acknowledged challenges in tracking attendance and the absence of a computer-based education system or educator.
A facility failed to notify a resident's representative and the Ombudsman in writing about an emergency hospital transfer. The resident, who had a history of hypertension, depression, and urinary tract infection, was transferred to the hospital without written notification. Interviews with the DON and LNHA revealed that the facility lacked a policy for sending such notifications.
A facility failed to provide a resident or their representative with written notification of its bed hold policy upon hospital transfer. Despite having a policy, the facility did not send out required notifications, as confirmed by interviews with the DON and LNHA. The resident, who was alert and oriented, was transferred to the hospital with an anticipated return, but no written notification was documented.
The facility failed to accurately code the MDS for three residents, leading to deficiencies in care management. One resident's MDS incorrectly indicated no use of a feeding tube, another's side rails were wrongly coded as restraints, and a third's MDS showed bed rails as restraints without proper documentation. These inaccuracies reflect a failure to follow federal guidelines.
A facility failed to administer oxygen therapy according to a physician's order for a resident with a diagnosis of malignant neoplasm of the bronchus or lung. The resident was observed receiving oxygen at four liters per minute, contrary to the prescribed three liters per minute as needed for shortness of breath. The electronic Treatment Administration Record lacked a nurse's signature confirming administration, and the facility's policy required adherence to physician's orders.
A facility failed to ensure a staff member assisting with feeding was properly trained and evaluated as a paid feeding assistant. A resident, recently placed on hospice and requiring feeding assistance due to a stroke, was fed by a Home Health Aide and nursing student without documented training or competency evaluation. The staff member was hired for clerical work, and the facility's policy required proper training for non-nursing personnel providing meal assistance.
Kitchen Sanitation and Storage Temperature Deficiencies
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. During an observation with the Food Service Director, a Dietary Aide was seen wearing large hooped earrings in the kitchen, and the aide stated they were not aware the earrings were prohibited. The Food Service Director acknowledged the issue and stated the kitchen staff would be educated. The surveyor also observed a dust-like buildup on each shelf of a 4-shelf dish storage rack, burnt-on food-like particles and a blackish grease-like substance on the griddle in the cooking area, and a dust-like substance on the fan covers in the walk-in refrigerator. In the dry storage room, a thermometer read 80 degrees Fahrenheit, above the facility’s stated storage range of 50 to 70 degrees Fahrenheit. Facility policies reviewed during the survey stated that jewelry, open-toe shoes, and long nails are prohibited, that surfaces in continuous use must be sanitized every 4 hours and large appliances wiped down daily, and that storage rooms should be maintained between 50 and 70 degrees Fahrenheit with good ventilation. The LNHA, DON, Infection Preventionist, and Prioress were later present for the exit conference, and no additional pertinent information was provided.
Feeding assistants assigned to residents with complex diets
Penalty
Summary
The facility failed to ensure that feeding assistant staff were assigned only to residents appropriate for the feeding assistant program and without complex diets. Resident #17 had diagnoses including Parkinson’s disease, epilepsy, unspecified dementia, and vision loss in both eyes, with a BIMS score of 0 indicating severe cognitive impairment. The resident’s records showed a mechanically altered/mechanical soft diet, a care plan intervention stating the resident needed encouragement to eat and to be fed all meals by feeding assistance, and a MAR order that the resident was fed all meals and snacks because the resident forgot how to feed themself. The speech evaluation stated the resident could tolerate a mechanical soft diet with thin liquids. Resident #28 had diagnoses including unspecified dementia and severe anxiety, with a BIMS score of 3 indicating severe cognitive impairment. The resident’s records showed a swallowing disorder, a mechanically altered/pureed diet, and an order that the resident was only to be fed when adequately alert. The care plan noted poor sleeping habits causing increased lethargy during the day and that speech therapy downgraded the resident’s diet to pureed. The speech evaluation described relatively severe dysphagia affecting the oral and pharyngeal phases and recommended a pureed diet with thin liquids under aspiration precautions, with nursing staff to feed the resident only when adequately alert. The DON stated the feeding assistants were the residents on the facility list and acknowledged there was a safety concern with feeding assistants assisting residents with altered or complex diets.
Call Bell Not Within Resident’s Reach
Penalty
Summary
The facility failed to keep Resident #25’s call bell within reach. On 5/28/26 at 10:10 AM, the surveyor observed the resident in bed with the call bell at the bottom of the bed, wrapped around the bed frame and not within reach. The resident’s record showed admission with diagnoses including chronic kidney disease, dementia, and a history of falls. The quarterly MDS dated 4/20/26 indicated severe cognitive impairment and the need for staff assistance with ADLs. The resident’s care plan identified the resident as high risk for falls and included interventions to ensure the call light was within reach and that requests for assistance received prompt response. When the surveyor showed the observation to the assigned RN at 10:20 AM, the RN acknowledged the call bell should have been left within the resident’s reach. Later, the DON also acknowledged that call bells should be within reach of all residents. A CNA assigned to the resident’s care on the day shift confirmed that she should have placed the call bell within the resident’s reach.
Incorrect Mattress Setting and Improper Wound Care Technique
Penalty
Summary
A specialty low air loss mattress was not accurately set for a resident who had chronic kidney disease, dementia, and a history of falls. The resident’s air mattress pump was observed set at 250 lbs., while the resident’s recorded weight was 143.8 lbs. The resident had a physician order for an alternating pressure air mattress with pump and for staff to check that the pump was set on the correct weight, and the treatment record showed the mattress was being monitored each shift. The assigned RN acknowledged that the setting should have matched the resident’s weight and stated that the correct setting was important to ensure the device’s effectiveness. A resident with diabetes mellitus and congestive heart failure had a right shin wound ordered for cleansing with normal saline, application of calcium alginate, and coverage with ABD pad and Kling twice daily. During observation of the wound treatment, the RN placed paper towels on the over-bed table without disinfecting it and set wound care supplies on the table in the resident’s room. The RN performed hand hygiene by applying soap and immediately placing her hands under running water without first lathering. After completing the wound care, the RN wrote directly on the dressing after it had already been applied rather than labeling it before application. The RN again performed hand hygiene in the same manner after the treatment. The surveyor discussed the infection control breaches with the RN, who acknowledged that she should have lathered her hands for 20 seconds before rinsing and should have initialed and dated the dressing prior to application. The facility’s skin integrity and wound care policy stated that nursing staff are knowledgeable and competent in providing basic prevention, assessment, and treatment to residents with wounds.
Failure to Update Fall Interventions and Follow Bedside Safety Orders
Penalty
Summary
The facility failed to provide new fall interventions following a resident’s fall, accurately code the MDS, and follow a physician order for residents with a history of falls. Resident #27 had diagnoses including dementia, Parkinson’s disease, and urinary incontinence, and the quarterly MDS showed a BIMS score of 12 of 15 with moderate cognitive impairment and indicated the resident had fallen since admission. The care plan identified the resident as at risk for falls related to Parkinson’s disease and a history of falls, with the last initiated and revised intervention stating that a fall mat should be used next to the bed while the resident was in it. However, the DON stated the care plan should have been updated with new interventions after the resident’s fall, and the quarterly MDS failed to capture the fall that occurred in 6/2025. Resident #25 was admitted with diagnoses including chronic kidney disease, dementia, and a history of falls. The quarterly MDS indicated severe cognitive impairment and the resident required staff assistance for ADLs. A physician order directed that a floor mat be placed to the left side of the bed every shift for safety while the resident was in bed, and the care plan also included a fall mat in place. During observation, the landing mat was folded against the wall and not placed on the floor next to the resident’s bed. The RN, DON, and CNA all acknowledged that the mat should have been in place on the left side of the bed per the physician order, and the CNA stated it may have been forgotten.
Indwelling Catheter Bag Left Uncovered
Penalty
Summary
The facility failed to follow physician orders, the individualized care plan, and facility policy by not providing a privacy bag for a resident with an indwelling urinary catheter. Resident #6 was observed in bed with the catheter drainage bag connected to the bedrail without a privacy bag, and the resident stated they did not recall having a privacy bag for the catheter. A later observation again found the catheter drainage bag not in a privacy bag. Record review showed the resident had diagnoses including urinary tract infection, urinary retention, and urinary incontinence, and the MDS indicated the resident had an indwelling catheter and a BIMS score of 15 out of 15. The physician order stated not to leave suprapubic catheter supplies and dressing out in view, and the care plan directed that the tube not be twisted and the bag always be covered. The facility policy also required the urinary bag to be covered with a privacy bag when in bed and in a wheelchair.
Oxygen Therapy Orders Not Followed and Care Plan Not Updated
Penalty
Summary
The facility failed to follow a physician’s order for oxygen therapy for a resident who was admitted with diagnoses including respiratory arrest, dependence on supplemental oxygen, and essential hypertension. The resident had severe cognitive impairment with a BIMS score of 0 out of 15 and was receiving oxygen via nasal cannula. During observation, the oxygen flow was seen at between 2.5 and 3 liters per minute, while an LPN stated the resident was supposed to be receiving 4 liters per minute. The record review showed multiple oxygen-related physician orders, including orders for oxygen at 2-4 L via nasal cannula for shortness of breath, checking that the concentrator matched the physician’s orders every shift, and oxygen at 4 L to maintain pulse oximetry above 90%, but the e-MAR did not reflect one of the orders and the e-MAR and e-TAR did not show documentation of oxygen saturation readings. The resident’s comprehensive care plan did not include a focus for oxygen use or therapy. Instead, it included a hospice-related focus statement and a dementia-related intervention referencing oxygen settings, but no separate oxygen therapy focus. The DON stated that the older oxygen order should have been discontinued and that a separate order for oxygen saturation should have been included, and also stated that oxygen use should have a separate focus in the CCP and be clear and aligned with the hospice care plan.
Incomplete Annual CNA In-Service Training
Penalty
Summary
The facility failed to ensure that all certified nursing assistants (CNAs) received the required 12 hours of annual mandatory in-service training by their anniversary date. Review of in-service records for 5 randomly selected CNAs showed that 3 did not meet the annual requirement: CNA #1, hired 3/14/2024, completed 11 hours and 12 minutes; CNA #2, hired 10/24/2024, completed 6 hours; and CNA #3, hired 12/5/2011, completed 11 hours and 42 minutes. During record review with the Infection Preventionist, who was also the Staff Educator, the surveyor was told that these 3 CNAs did not meet the required 12 hours of annual in-services. The LNHA and DON later acknowledged that the CNAs did not meet the required education, and the facility policy stated that CNA staff in-service training was to be completed yearly.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nursing Aides (CNAs) received annual performance reviews, as required by their policy. During a survey, the Licensed Nursing Home Administrator (LNHA) was unable to provide performance reviews for five randomly selected CNAs. The LNHA admitted that the Director of Nursing (DON) had the forms necessary for the reviews but had not completed them. This lack of documentation was confirmed during interviews with the LNHA and DON, who acknowledged the absence of performance reviews for the CNAs. The facility's policy, effective since March 2018, mandates that employee evaluations be scheduled annually to provide feedback, distribute rewards, identify development opportunities, and address performance issues. Despite this policy, the DON, who had been in the position for seven months, had not conducted any performance reviews during her tenure. The facility did not provide any additional information or evidence to demonstrate compliance with their policy, resulting in a deficiency finding by the surveyors.
Deficiency in CNA Training Hours and Mandatory Education
Penalty
Summary
The facility failed to ensure that Certified Nurses Aides (CNAs) received the required 12 hours of mandatory in-service training. This deficiency was identified for all five CNAs reviewed. The Licensed Nursing Home Administrator (LNHA) acknowledged that the facility did not have a computer-based education system or an educator, and that capturing attendance for in-person sessions was challenging. The LNHA could not provide evidence of 12 hours of education for each CNA, and the sign-in sheets indicated that the in-services were only one hour or slightly longer. Additionally, CNA #1 did not receive training in abuse prevention and resident rights, which are mandatory. The facility's policy on nursing staff education, reviewed in 2023, outlined required yearly education topics, including abuse/neglect, Alzheimer's disease, infection control, resident rights, and CPR. However, the policy did not specify the number of hours required for CNAs. The LNHA admitted that the facility needed to improve tracking of education and confirmed the deficiency in providing the required training hours and mandatory topics for the CNAs. No additional information or documentation was provided by the facility to address these deficiencies.
Failure to Notify Resident's Representative and Ombudsman of Emergency Transfer
Penalty
Summary
The facility failed to provide written notification to the resident's representative and the Office of the Ombudsman for an emergency transfer to the hospital. This deficiency was identified for a resident who was reviewed for hospitalization. The resident, who was alert and oriented, was observed during medication administration. The resident's medical records indicated a history of hypertension, depression, and urinary tract infection. The Discharge Minimum Data Set (MDS) showed that the resident was discharged to the hospital with an anticipated return to the facility. However, there was no written notification sent to the resident's representative or the Ombudsman regarding this transfer. Interviews with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) revealed that the facility did not have a policy in place for sending written notifications for emergency transfers. The DON stated that while the resident's representative was verbally notified, no written communication was sent. The LNHA confirmed that the facility did not send out such letters and had no policy requiring it. This lack of written notification was discussed with the LNHA and the DON, who acknowledged the absence of a policy and did not provide further information.
Failure to Provide Written Bed Hold Notification
Penalty
Summary
The facility failed to provide appropriate written notification of its bed hold and reserve payment policy to a resident or their representative upon transfer to the hospital. This deficiency was identified during a surveyor's observation and review of the medical records for a resident who was transferred to the hospital. The resident, who was alert and oriented, had been admitted to the facility with diagnoses including hypertension, depression, and a history of urinary tract infection. The resident was discharged to the hospital with an anticipated return to the facility, but there was no evidence of written notification regarding the bed hold policy being provided to the resident or their representative. Interviews with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) revealed that the facility did not send out written emergency transfer or bed hold letters to residents' representatives or the Ombudsman Office. The DON and LNHA both stated that the facility guarantees a bed for residents upon their return from the hospital, but acknowledged that there was no policy in place for sending out such notifications. Despite having a bed hold policy, the facility did not adhere to the requirement of providing written information to residents or their representatives, as evidenced by the lack of documentation in the resident's records.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in the management of their care. For one resident, the MDS was incorrectly coded regarding the use of a feeding tube. The resident was transitioning off tube feeding and only receiving water flushes, yet the MDS indicated no use of a feeding tube. This discrepancy was acknowledged by the Registered Dietitian, who admitted to entering the dietary information incorrectly. Another resident's MDS was inaccurately coded concerning the use of side rails. The resident used side rails to assist with mobility, but the MDS coded them as restraints. The MDS Coordinator and Director of Nursing had differing opinions on whether the side rails should be considered restraints or enablers, leading to confusion and incorrect coding on the MDS. The third resident's MDS indicated the use of bed rails as restraints, but there was no physician's order or care plan for bed rail use. The Director of Nursing confirmed that there were no restraints in the facility, highlighting a lack of documentation and assessment for the use of bed rails. These inaccuracies in MDS coding reflect a failure to adhere to federal guidelines and accurately assess the residents' needs.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for a resident who was reviewed for respiratory care. The surveyor observed the resident in bed with a nasal cannula connected to an oxygen concentrator set at four liters per minute, contrary to the physician's order of three liters per minute as needed for shortness of breath. The resident's medical record indicated an intact cognitive status and a diagnosis of malignant neoplasm of the bronchus or lung. The physician's order for oxygen therapy was not properly documented in the electronic Treatment Administration Record, as it lacked a nurse's signature confirming administration. During the survey, the Registered Nurse confirmed that the resident was on continuous oxygen at four liters per minute, which was inconsistent with the physician's order. The facility's policy on oxygen administration, effective December 2023, stated that oxygen should be administered according to the attending physician's orders, particularly for PRN orders. The Licensed Nursing Home Administrator and the Director of Nursing were unable to provide further information during the surveyor's interview.
Inadequate Training for Feeding Assistance
Penalty
Summary
The facility failed to ensure that staff members assisting residents with feeding were appropriately trained and evaluated as competent to be paid feeding assistants. This deficiency was observed when a surveyor entered a resident's room and found a staff member, identified as a Home Health Aide (HHA) and nursing student, feeding a resident without documented evidence of having completed a paid feeding assistant course or competency evaluation. The staff member was hired for clerical work, and there was no signed job description or indication of her position in her personnel file. The resident involved had been admitted with diagnoses including cerebral infarction and hypertension and was recently placed on hospice services. Despite being cognitively intact, the resident required assistance with feeding due to a recent stroke. The staff member, although a licensed CNA in Florida and a second-year nursing student, was not officially trained or evaluated by the facility to perform feeding duties, as confirmed by the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA). The facility's policy on paid feeding assistance outlined that non-nursing personnel could provide minimal assistance with meals after proper training. However, the staff member in question did not receive such training or competency evaluation from the facility. The DON acknowledged that the staff member should not have been feeding residents according to her title, and there was no additional information provided by the facility to address the concern raised by the surveyor.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Caldwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Hill | 1.2 mi | ★★★★★ | 6 | 0 |
| Lutheran Social Ministries Cranes Mill | 1.8 mi | ★★★★★ | 0 | 0 |
| Complete Care At West Caldwell Llc | 1.9 mi | ★★★★★ | 1 | 0 |
| Canterbury At Cedar Grove | 2.2 mi | ★★★★★ | 13 | 0 |
| Alaris Health At Cedar Grove | 2.3 mi | ★★★★★ | 2 | 0 |
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