Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Nrsg And Rehab Care Center during CMS and state inspections, most recent first.
Late completion of comprehensive MDS assessments was identified for multiple residents after record review and review of the MDS Validation Report. The facility policy did not include specific timing guidance, and the former MDS coordinator, DON, and Administrator each stated they were unaware of the late submissions or the related error messages.
Late completion of quarterly MDS assessments affected 12 residents reviewed during the survey. The MDS Coordinator stated the assessments should be completed within 14 days of the assessment reference date, but the Validation Report showed the quarterly MDSs were late and the error messages were not noticed. The DON and Administrator said they were not aware of the late assessments, and the issue had not been discussed at a QA meeting.
Late Transmission of MDS Assessments: Surveyors found that multiple completed MDS assessments were not electronically transmitted to CMS within the required timeframe. The issue affected many residents reviewed, and record review showed some assessments were transmitted weeks late. The MDS coordinator reported not noticing late submission error messages on the validation reports and stated there was a computer issue, while the DON and Administrator said they were not aware of the late transmissions.
A resident with COPD, HTN, and CHF had an EMR preset order directing CNAs to replace an oxygen tank when the gauge was low, even though facility policy stated only licensed nurses could adjust oxygen flow and CNAs were only to monitor the tank and notify the nurse. The CNA accountability record showed CNAs signed each shift as if they followed the order, while an LPN, CNA, staff educator, medical director, attending physician, and DON all stated CNAs are not allowed to change oxygen tanks.
Failure to use required eye protection during COVID-19 droplet precautions. A resident with COVID-19, nasal congestion, and coughing was on transmission-based precautions, but a CNA entered the room to serve lunch without an eye shield while the resident was not wearing a mask. The CNA said no eye shield was available in the PPE cart, and the IP and DON confirmed eye protection should have been worn.
During a Recertification and Abbreviated Survey, it was found that two residents with cognitive impairments were subjected to abuse by a CNA. One resident with Dementia, Stroke, and Anxiety was slapped and restrained by the CNA, who claimed the resident was combative. Another resident with Morbid Obesity, Hypertension, and Major Depressive Disorder was roughly handled, resulting in harm. The facility's Abuse Prohibition policy mandates immediate reporting of abuse, but there was a lack of proper assessment, documentation, and timely reporting of these incidents, contributing to the continuation of abusive behavior.
The facility failed to report an incident of abuse involving a resident who was roughly handled by a CNA. Despite the resident's complaints of pain and fear of retaliation, the incident was not reported to the New York State Department of Health as required.
A facility failed to investigate an alleged abuse incident where a CNA was observed roughly handling a resident during care. Despite the incident being reported to an LPN and a Registered Nursing Supervisor, no investigation was initiated. The resident involved had multiple diagnoses and required maximum assistance for mobility.
The facility failed to update a resident's Comprehensive Care Plan to reflect a change from Full Code to DNR status, resulting in a 21-day delay. The delay occurred despite the physician's order and notification to the responsible Social Worker, who forgot to make the necessary updates.
Late Completion of Comprehensive MDS Assessments
Penalty
Summary
The facility did not ensure that comprehensive Minimum Data Set (MDS) assessments were completed within 14 calendar days after the assessment reference date and at least every 12 months for 10 of 47 residents reviewed. Residents #81, #87, #88, #100, #109, #127, #148, #291, #302, and #303 all had comprehensive MDS assessments that were not completed within the required 14-day timeframe. The deficiency was identified during the recertification survey based on record review and review of the facility’s MDS 3.0 Nursing Home Validation Report, which showed the late completions. The facility’s policy titled MDS Assessment Schedule & Completion, effective 05/28/2025, stated that each resident admitted to the facility would be assessed using the MDS tool and that the information would be encoded and electronically transmitted to the State survey agency, but it did not include specific guidance on the timeframe for completing comprehensive MDS assessments. During interviews, the former MDS Coordinator stated that assessments should be completed within 14 days of the assessment reference date and that late completion error messages were not noticed on the Validation Reports. The DON stated they were not aware of the late MDS assessments, and the Administrator stated they had not been informed of the late assessments and that the issue had not been discussed at a QAA meeting.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility did not ensure that quarterly Minimum Data Set (MDS) assessments were completed not less frequently than once every three months for 12 of 47 residents reviewed for the Resident Assessment Facility Task. The residents identified were #46, #51, #54, #71, #74, #78, #82, #85, #189, #227, #235, and #285, and their quarterly MDS assessments were not completed within 14 days of the assessment reference date. The facility policy titled Minimum Data Set (MDS) Assessment Schedule & Completion, effective 05/28/2025, stated that each resident admitted to the facility would be assessed using the MDS tool and that information gathered would be encoded and electronically transmitted to the State survey agency, but it did not include specific guidance for completion timeframes. Review of the MDS 3.0 Nursing Home Validation Report showed the quarterly assessments for the 12 residents were late. During interviews, the former MDS Coordinator stated the assessments should be completed within 14 days of the assessment reference date and said the late completion error messages were not noticed on the Validation Reports. The DON stated they were not aware of the late assessments, and the Administrator stated they had not been informed of the late MDS assessments and that the issue had not been discussed at a QA meeting.
Late Transmission of MDS Assessments
Penalty
Summary
The facility did not ensure that completed MDS assessments were electronically transmitted to CMS within 14 days of the resident assessment completion date. During the recertification survey, surveyors identified this issue for 28 of 47 residents reviewed for the Resident Assessment Facility Task, including Residents #303, #37, #40, #42, #46, #54, #65, #71, #78, #81, #85, #87, #89, #109, #116, #127, #157, #171, #189, #211, #215, #220, #222, #223, #235, #256, #259, and #285. The facility policy titled Minimum Data Set (MDS) Assessment Schedule & Completion stated that each resident would be assessed using the MDS tool and that information gathered would be encoded and electronically transmitted to the State survey agency, but it did not include specific guidance on the timeframe for transmission to CMS. Record review showed that multiple assessments were transmitted late, including Resident #303’s admission MDS, which was completed on 04/07/2025 and transmitted on 04/30/2025, and Resident #291’s Significant Change MDS and Resident #285’s Quarterly MDS, both completed on 06/11/2025 and transmitted on 08/13/2025. During interview, the former/current MDS Coordinator stated that assessments should be submitted within 14 days of completion and that late submission error messages were not noticed on the Validation Reports. The MDS Coordinator also stated there was a computer issue and they did not realize the records had not properly transmitted. The DON stated they did not know there were late submissions, and the Administrator stated they were not informed of the late MDS assessments and that the issue had not been discussed in QA meetings.
Incorrect CNA Oxygen Tank Order in Resident Record
Penalty
Summary
The facility did not maintain accurately documented medical records in accordance with accepted professional standards for one resident receiving respiratory care. A preset physician order was created in the electronic record directing CNAs to check and replace the oxygen tank when the oxygen supply was low, even though the facility’s policies stated that only licensed nurses were permitted to adjust oxygen flow rate and that CNAs were only to confirm the tank was present and notify the nurse when the gauge was in the red area. The resident had diagnoses including COPD, hypertension, and CHF, and the quarterly MDS documented respiratory treatment including oxygen therapy for COPD. The current physician’s order directed continuous oxygen at 3 liters per minute for shortness of breath every shift, and also directed CNAs to check the oxygen tank each shift and replace it if the gauge was in the red area. The resident’s care plan included positioning for optimal breathing, administering medications and oxygen therapy per physician’s order, and observing and reporting signs of respiratory distress. The CNA accountability record showed CNAs signed each shift indicating they followed the order to replace the tank and ensure it was turned off when not in use. During interviews, an LPN stated CNAs were not responsible for replacing oxygen tanks and should call the nurse if replacement was needed, a CNA stated they only monitor the tank and have the nurse replace and calibrate it, and the staff educator stated they created the preset order and that it should have directed CNAs to retrieve the tank and inform the nurse instead of replacing it. The medical director, attending physician, and DON all stated that CNAs are not allowed to change oxygen tanks.
Failure to Use Required Eye Protection During COVID-19 Droplet Precautions
Penalty
Summary
Provide and implement an infection prevention and control program. During a recertification survey, the facility was found not to have maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent communicable diseases and infections. The deficiency involved one resident, who tested positive for COVID-19 and was placed on Droplet Precautions. The resident’s diagnoses included COVID-19 infection, Allergic Rhinitis with runny and itchy nose and sneezing, and Alzheimer’s disease. The admission MDS documented a BIMS score of 15, indicating intact cognition, and the resident used a wheelchair and walker for ambulation. The resident’s care plan for COVID-19 documented transmission-based contact and droplet precautions, along with education to follow COVID-19 infection control protocols, including wearing a face covering during care, visitation, and while out of the room. On the day of the observation, the resident had nasal congestion, had been placed on increased COVID-19 symptom monitoring and transmission-based precautions after a positive rapid COVID-19 swab, and was observed sitting in a wheelchair next to the bed, coughing and not wearing a mask. A CNA was observed inside the resident’s room serving lunch without eye protection. The CNA stated there was no eye shield in the PPE cart and that they should have obtained one before entering the room. The Infection Preventionist and the DON both stated the CNA should have worn an eye shield while caring for the resident.
Abuse Incidents Involving Residents with Cognitive Impairments
Penalty
Summary
During the Recertification Survey and Abbreviated Survey conducted at the facility, it was identified that two residents, Resident #9 and Resident #157, were subjected to abuse by Certified Nursing Assistant #1. Certified Nursing Assistant #2 witnessed Certified Nursing Assistant #1 slapping Resident #9 on the leg and holding the resident's wrist to prevent biting. Following this, Certified Nursing Assistant #2 observed Resident #157 being roughly handled by Certified Nursing Assistant #1 during care, resulting in actual harm to Resident #157. The facility's Abuse Prohibition policy clearly outlined the zero-tolerance stance towards abuse and the obligation to report any suspicions of abuse immediately to the appropriate authorities. Resident #9, diagnosed with Dementia, Stroke, and Anxiety, had severe cognitive impairment and required assistance for mobility and transfers. Despite a history of refusing treatments, there was no documented assessment related to the abuse incident in the nursing, medical, or social work progress notes. Certified Nursing Assistant #1 justified their actions by claiming Resident #9 was combative, but their response to the situation was deemed inappropriate and abusive. Resident #157, diagnosed with Morbid Obesity, Hypertension, and Major Depressive Disorder, had moderate cognitive impairment and required significant assistance for daily activities. During an interview, Resident #157 recounted being roughly handled by Certified Nursing Assistant #1, expressing fear of retaliation and distress from the incident. The facility's failure to promptly address and document the abuse incidents involving Resident #9 and Resident #157 highlights a significant deficiency in ensuring resident safety and protection from abuse. The lack of proper assessments, documentation, and immediate reporting of the incidents by staff members, as outlined in the facility's policies, contributed to the continuation of abusive behavior towards the residents. The interviews with staff members, including Certified Nursing Assistant #1, Certified Nursing Assistant #2, Licensed Practical Nurse #1, and the Director of Nursing, provided insights into the events leading to the deficiency and the subsequent actions taken by the facility to investigate and address the abuse allegations.
Failure to Report Abuse in a Timely Manner
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse were reported immediately to the New York State Department of Health. This deficiency was identified for one resident who was roughly handled by a Certified Nursing Assistant (CNA) during care. Specifically, CNA #2 witnessed CNA #1 roughly handling Resident #157 by abruptly removing the resident's blanket and pulling the resident by their arms and legs while turning them in bed. Despite Resident #157's complaints of pain, CNA #1 continued to provide care in a rough manner. The facility failed to report this allegation of abuse to the New York State Department of Health as required. The incident was initially reported by CNA #2 to Licensed Practical Nurse (LPN) #1, who then informed the Registered Nurse Supervisor (RNS) #1. However, the report did not include the details of the rough handling of Resident #157. The RNS assessed Resident #157 but did not document any findings related to the rough handling. Additionally, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were not informed of the specific details of the rough handling and the resident's verbalization of pain, leading to a failure to report the incident to the state authorities. Resident #157, who has diagnoses including Morbid Obesity, Hypertension, and Major Depressive Disorder, recalled the incident and expressed fear of retaliation. The resident described the rough handling and the pain experienced during the care provided by CNA #1. Despite these details, the facility's administration did not report the incident to the New York State Department of Health, citing a lack of information about the arm pulling and the resident's complaints of pain. This failure to report the abuse in a timely manner constitutes a significant deficiency in the facility's compliance with abuse reporting regulations.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to initiate and complete an investigation of an alleged violation of abuse involving a resident. On the specified date, a Certified Nursing Assistant (CNA) was observed by another CNA roughly handling a resident during care, including abruptly removing the resident's blanket and pulling the resident's arms and legs. Despite the incident being reported to a Licensed Practical Nurse (LPN) and subsequently to a Registered Nursing Supervisor, no investigation was initiated for the resident involved in the rough handling incident. The resident involved had diagnoses including Morbid Obesity, Hypertension, and Major Depressive Disorder, and was documented to have moderate cognitive impairment. The resident required maximum assistance for bed mobility and transfers. The incident was not documented in the resident's nursing or social work progress notes, and no assessment was conducted following the incident. Interviews with staff revealed that the CNA who witnessed the rough handling reported the incident to the LPN, who then reported it to the Registered Nursing Supervisor. However, the Registered Nursing Supervisor did not initiate an investigation. The Director of Nursing and Assistant Director of Nursing confirmed that an investigation should have been completed for the resident involved in the rough handling incident.
Failure to Update Resident's Advance Directives in Care Plan
Penalty
Summary
The facility did not ensure that Resident #178's Comprehensive Care Plan was reviewed and revised to reflect the current needs of the resident. Specifically, the care plan was not updated to reflect a change in the resident's Advance Directives from a Full Code status to a Do Not Resuscitate (DNR) status. This discrepancy was identified during a Recertification Survey, where it was found that the care plan was updated 21 days after the physician's order was obtained, indicating a significant delay in updating the resident's care plan. Resident #178, who had diagnoses including Atrial Fibrillation and Syncope, was observed participating in a recreational activity in the dining room. The resident's Brief Interview for Mental Status score indicated moderately impaired cognition. Despite the physician's order for DNR being documented, the care plan continued to reflect a Full Code status. Interviews with the Registered Nurse Manager and Social Worker revealed that the delay was due to the Social Worker forgetting to update the care plan, even though they were informed of the change in advance directives.
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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 Smithtown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookside Multicare Nursing Center | 0.1 mi | ★★★★★ | 3 | 0 |
| Smithtown Center For Rehabilitation & Nursing Care | 1.8 mi | ★★★★★ | 3 | 0 |
| The Hamlet Rehabilitation And Healthcare Center At | 2 mi | ★★★★★ | 0 | 0 |
| St James Rehabilitation & Healthcare Center | 3.3 mi | ★★★★★ | 10 | 0 |
| Luxor Nursing & Rehabilitation At Mills Pond | 3.3 mi | ★★★★★ | 0 | 0 |
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