Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,446 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St Catherine Of Siena.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.