Cycle 1
Health 2025-01-07 · Fire 2025-01-07
7 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Caldwell, NJ
St Catherine Of Siena
2-star overall rating with 3-star inspections with $16,171 in total fines with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
7 Ryerson Avenue, Caldwell, NJ
(973) 226-1577
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
26
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-09-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.14
Licensed practical nurse staffing · state 0.94 · national 0.87
Aide hours / resident day
1.09
Nurse aide staffing · state 2.23 · national 2.35
Total nurse hours
1.73
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
0.64
RN + LPN hours · state 1.62 · national 1.54
Weekend hours
1.71
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
2.10
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
23%
Annual nurse turnover · state 41% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 7 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 9.86% |
8.2%
1.7 pts better
|
Numerator 7 · Denominator 71 |
| Staff flu vaccination coverage | 92% |
42%
50 pts better
|
Numerator 69 · Denominator 75 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.1
0.7 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 1.8 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.1
0.1 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.0%
7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.2%
2.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 11.9% |
2.4%
9.5 pts worse
|
3.3%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 11.1% · Q3 16.7% · Q4 12.0% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
11.4%
11.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
4.6%
0.5 pts worse
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.5% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.8% |
19.0%
9.8 pts worse
|
19.6%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 40.9% · 4Q avg 28.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
13.5%
6.7 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.5% |
9.8%
2.7 pts worse
|
16.3%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
9.7%
3.5 pts worse
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 20.0% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.7%
0.1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 39.2% |
15.9%
23.3 pts worse
|
19.8%
19.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 40.1% · Q3 34.8% · Q4 47.3% · 4Q avg 39.2% |
| Percentage of long-stay residents with pressure ulcers | 13.5% |
6.0%
7.5 pts worse
|
5.1%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 16.5% · Q3 15.0% · Q4 9.5% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
78.7%
17.6 pts better
|
81.7%
14.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 96.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-12 · Fire 2023-10-12
6 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-10-06 · Fire 2022-10-06
5 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-07
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-01-31
F · Potential for more than minimal harm
2025-01-07
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-02-03
F · Potential for more than minimal harm
2025-01-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-26
F · Potential for more than minimal harm
2025-01-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-26
F · Potential for more than minimal harm
2025-01-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-14
F · Potential for more than minimal harm
2025-01-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-14
E · Potential for more than minimal harm
2025-01-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-14
E · Potential for more than minimal harm
2023-10-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-10-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-10-12
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-10-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-25
F · Potential for more than minimal harm
2022-10-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-28
F · Potential for more than minimal harm
2022-10-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-28
F · Potential for more than minimal harm
2022-10-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-28
F · Potential for more than minimal harm
2022-10-06
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2022-11-28
E · Potential for more than minimal harm
2022-10-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-10-26
E · Potential for more than minimal harm
2022-10-06
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-12-19
E · Potential for more than minimal harm
2022-10-06
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-11-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-07
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-01-31
F · Potential for more than minimal harm
2025-01-07
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-07
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-07
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-07
F811 · Nutrition and Dietary Deficiencies
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2025-01-31
E · Potential for more than minimal harm
2023-10-12
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-10-12
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-10-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-10-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-10-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-10-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-29
F · Potential for more than minimal harm
2022-10-06
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-12-08
D · Potential for more than minimal harm
2022-10-06
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-11-30
D · Potential for more than minimal harm
2022-10-06
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-10-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-28
C · Minimal harm
2022-10-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-11-28
Penalties and ownership
What sits behind the stars
$9,116
2024-01-30
Fine
Fine · fine $9,116
Fine
$2,117
2023-11-13
Fine
Fine · fine $2,117
Fine
$1,764
2023-11-06
Fine
Fine · fine $1,764
Fine
$3,174
2023-10-17
Fine
Fine · fine $3,174
Fine
Ownership
Ramm, Luella
Corporate Officer · Individual
Wittler, Judith
Operational/Managerial Control · Individual
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