Elizabeth Seton Children's Center

Based on observation, interview, and record review conducted during the recertification and abbreviated surveys (NY00381153/462978) from 7/31/25 to 8/7/25, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for one of two residents (Resident #119) reviewed for accidents. Specifically, staff did not perform a time out to double check if all strap eyelets were secured on the mechanical lift hooks prior to raising the lift up and Resident #119 slid out of the sling and dropped to the floor.Findings include:Resident #119 had diagnoses including cerebral palsy, seizure disorder, dependence on respirator, tracheostomy, and gastrostomy. The 12/31/20 Falls Care Plan documented the resident was at risk for falls related to lack of safety awareness, cognitive impairment, impaired balance, lack of voluntary extremity movements, spastic quadriplegia, and psychoactive drug use. The 2/21/25 Annual Minimum Data Set assessment documented Resident #119 had severely impaired cognition, was rarely/never understood, and was dependent on staff for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interviews during the recertification survey from 7/31/25 to 8/7/25, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #72) reviewed for infection control. Specifically, Resident #72 was on contact precautions until 8/1/25 and a housekeeper was observed doing a terminal cleaning of Resident #72's room and did not use the proper personal protective equipment while removing a privacy/cubicle curtain. Findings include:The Terminal Room Cleaning Policy dated 12/2012 documented when a room comes off isolation or when a resident is discharged , terminal cleaning will occur. The purpose is to provide residents, staff, and visitors with a sanitary and comfortable environment and endeavor to prevent the development and transmission of infection. It further documented in the procedures to make sure to wear personal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews completed during an abbreviated survey (NY00349237), the facility did not ensure that a resident received treatment and care in accordance with their comprehensive person-centered care plan. Specifically Resident #1 had a care plan in place, that documented that they required 2 staff members to provide all care. On 7/23/2024 a single Certified Nurse Aide provided care singlehandedly to Resident #1. The finding is: The facility policy titled Lifting and transferring a Child revised on 11/2024 documents that all lifting, and transfers are conducted by trained direct care staff and or clinical staff and or trained family members. It further documened that once the transfer designation is established in the care plan it must be followed at all times within the facility by all direct caregivers. Resident #1 originally admitted on [DATE], readmitted on [DATE] with diagnoses including, but not limited to, spastic cerebral palsy with quadriparesis, epilepsy, disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during an abbreviated survey (NY00345276) on 6/20/24, the facility did not ensure residents rights to be free from physical for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, on 6/12/24, two facility staff (Certified Nurse Aide #1 and Speech Therapist #2) witnessed an alleged staff to resident abuse involving Registered Nurse #7 and Resident #1. Registered Nurse #7 was witnessed screaming 25year olds don't behave this way-cut it out and holding Resident #1's hands down in their lap with closed hands over forearms. In an interview with Certified Nurse Aide #1 they stated they heard raised voices and saw Registered Nurse #7 loudly saying stop, are you a baby? Both witnesses did not report the incident on 6/12/24. The Speech Therapist #2 reported the incident to the administration on 6/13/24. Video surveillance revealed Registered Nurse #7 restraining Resident #1 by closing their hands on Resident #1 forearms and saw Registered Nurse #7 pointing a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during an abbreviated survey (NY00345276), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than two hours to the New York State Department of Health, and the results of the 5-day investigation to the New York State Department of Health in accordance with state law within 5 working days of the incident. This was identified for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, on 6/12/24, two facility staff (Certified Nurse Aide #1 and Speech Therapist) witnessed an alleged staff to resident abuse involving Registered Nurse #7 and Resident #1, which was not reported to the facility administration until 6/13/24. Certified Nurse Aide #1 did not report the incident on 6/12/24. The Speech Therapist reported the incident to the administration on 6/13/24. The result of the facility 5-day investigation was not submitted to New York State Department of Health until 6/21/24. Finding include: The facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews conducted during an abbreviated survey (NY00327790), the facility did not ensure that 1 of 21 sampled residents (Resident #1) was free from physical, verbal, and emotional abuse. Specifically, Certified Nurse Aide (CNA#3) witnessed CNA#1 slap Resident #1 on the face on 11/06/2023 while providing care and witnessed CNA#1 being rough in handling some of the residents in their unit. In addition, CNA#2 reported they witnessed CNA#1 being rough in handling some of the residents on their unit. The findings are: The Facility Policy on the Prohibition and Prevention of Resident Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property last revised on 06/2023 documented that it is the facility policy to honor all resident rights and treat each resident with respect and compassion in full recognition of the person's dignity and individuality. Resident #1 had diagnoses that included Lennox Gastaut Syndrome (A severe condition characterized by repeated seizures/epilepsy), Spastic Cerebral Palsy (A developmental disorder caused by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews conducted during an abbreviated survey (NY00327790), the facility did not ensure an alleged violation involving abuse was reported to the New York State Department of Health (NYS DOH) within 2 hours of occurrence. This was evident for 1 out of 21 residents (Resident #1) reviewed for abuse and mistreatment. Specifically, the facility reported a staff-to-resident abuse that occurred on 11/06/2023 to the NYSDOH on 11/09/2023. The findings are: The Facility Policy on Reporting and Investigation of Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Resident Property and Other Incidents effective 11/2022, revised on 06/2023 documented that all staff reports all reportable incidents immediately to the manager/supervisor or to the [NAME] President of Operations/Administrator. The facility immediately conducts a preliminary investigation and, if warranted, reports to the New York State Department of Health (NYS DOH), other agencies and law enforcement as specified in law and regulation within required timeframes. Resident #1 had diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon observation, interview, and record review conducted during the recertification survey on 7/31/2023 - 8/4/2023, the facility did not ensure that foods were stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1. unwrapped, uncooked ground beef was stored in a walk-in refrigerator, 2. an unsecured chest freezer located in a hallway near the kitchen contained foods intended for consumption by residents which were not labeled with expiration dates or use by dates, and 3. A dietary staff member was observed checking food temperatures prior to meal service and did not properly sanitize the thermometer. The findings are: During the initial and follow up tours of the kitchen on 7/31/2023 at 9:33 AM and on 8/2/2023 at 10:55 am the following were observed: 1. Observation on 7/31/23 at 9:57 AM revealed approximately one pound of ground beef stored in a walk in refrigerator. The ground beef was not adequately wrapped, and one side of the beef was open to the air and to contamination. In an interview conducted at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon observation, record review, and interviews conducted during the recertification survey on 7/31/2023 - 8/4/2023, the facility did not ensure that the garbage storage area was maintained in a sanitary condition. Specifically, the ground under the loading dock located near the door to the trash compactor was heavily littered with solid debris including two (2) treatment items labeled with personal health information. The findings are: An Environmental Services (ES) policy and procedure dated 12/2008 and titled Non-Hazardous Waste Removal documented the policy is To remove all trash from the facility in a safe and sanitary condition., and the purpose is To provide residents, staff, and visitors with a sanitary and comfortable environment and endeavor to prevent the development and transmission of infection. Procedures included that assigned housekeeping staff collect trash per schedule removing and sealing the clear plastic liners from each wastebasket, each sealed plastic liner is placed in a large trash bin on wheels, the trash is wheeled to/emptied into a dumpster at least…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of video evidence during the recertification survey and abbreviated survey (NY00296893) from 7/31/2023 to 8/4/2023, it could not be ensured that the facility provided the necessary care and treatment in accordance with professional standards of practice and the resident's patient centered comprehensive care plan. This was evident for 2 (Resident #64 and #319) of 5 residents reviewed for injury of unknown origin. Specifically, 1. video evidence revealed that on the evening of 6/1/2022 staff did not follow facility transfer protocol resulting in Resident #64 being transferred improperly and 2. a 6/18/2022 video revealed Resident #319 entering Resident #64's room and moving about the room freely, without indication of supervision or redirection for a time frame greater than one hour. The findings are: 1. Resident #64 was admitted with Lennox-Gastaut syndrome, congenital malformations of corpus callosum, disorders of bone density and structure, and dislocation of left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that food brought in from the outside was handled according to professional standards of practice. Specifically, food items found in the refrigerators on resident units were either outdated or not labeled and dated. This was evident on 2 of 8 resident units ([NAME] Park and [NAME] Park). The findings are: Leftovers and Food Safety Often when we cook at home or eat in a restaurant, we have leftovers. To ensure that leftovers are safe to eat, make sure the food is cooked to a safe temperature and refrigerate the leftovers promptly. Not cooking food to a safe temperature and leaving food out at an unsafe temperature are the two main causes of foodborne illness. Safe handling of leftovers is very important in reducing foodborne illness. Follow the USDA Food Safety and Inspection Service's recommendations for handling leftovers safely. Store Leftovers Safely Leftovers can be kept in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.