Cathedral Health Care Center

In the surveyor’s words

From the most serious findings on record at Cathedral Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Sep 21, 2021

  Based on interview and record review, the facility failed to ensure a resident with an extensive psychiatric history and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was started on [MEDICATION(S)], a medication which was toxic to the kidneys, which resulted in hospitalization for [MEDICATION(S)] toxicity. This affected 1 of 3 residents reviewed with behaviors and [CONDITION(S)] medications. (Resident B) Findings include: The closed clinical record of Resident B was reviewed on 9/20/21 at 10:50 A.M. The resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF690Jul 15, 2021

  Based on observation, interview, and record review, the facility failed to ensure that appropriate treatment and services were provided for an incontinent resident with a UTI (urinary tract infection) that resulted in a sharp decline in mental status with increased behaviors for 1 of 1 resident reviewed for UTI. A resident's UTI was not treated in a timely manner, the physician was not notified of a positive urine result, and the resident was incorrectly medicated. (Resident 12) Finding includes: On 7/13/21 at 2:14 P.M., Resident 12 was observed lying in bed with a full food tray on her bedside table. She indicated I can't hear what I'm saying, as well as other nonsensical speech. On 7/14/21 at 9:28 A.M., CNA 5, CNA 2, and RN 6 were observed to provide incontinence care for Resident 12. […]

• No harm, potential for more than minimal, patternF880Sep 13, 2024

  Based on observation, record review, and interview, the facility failed to ensure a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for 2 of 5 residents observed for care, and 2 of 10 residents reviewed for medication administration. Staff did not wash hands with at least a 20 second lather, did not change gloves and perform hand sanitization from dirty to clean tasks, did not wear gloves when administering an injection, and touched resident pills with bare hands. (Resident 34, Resident 37, Resident 20, Resident 9) Findings included: 1. On 9/9/24 at 7:27 A.M., RN (Registered Nurse) 15 was observed during a medication administration to Resident 20. RN 15 came out of the pantry room upstairs with a drink for the resident. […]

• No harm, potential for more than minimal, patternF812Sep 11, 2023

  Based on interview, observation, and record review, the facility failed to ensure food was stored and prepared safely in accordance with professional standards for food service for 2 of 2 kitchen observations. The staff lacked knowledge of the test strips used to test the sanitation chemicals in 1 of 2 observations of dishwasher use. Foods were not labeled correctly and a used cooking utensil was dropped into the food to be served. Findings include: 1. On [DATE] at 9:53 A.M., the following was observed in the kitchen: 5- loaves of bread were on a shelf not labeled Refrigerator: Mechanical sausage dated ,d+[DATE] (no year) Beef stew dated ,d+[DATE] (no year) Gravy dated ,d+[DATE] (no year) Gallon of dill pickles opened ,d+[DATE] (no year) Pear sauce dated ,d+[DATE] (no year) 4 packs of… […]

• No harm, potential for more than minimal, patternF921May 19, 2022

  Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and sanitary environment was maintained in 2 of 2 resident halls, 1 of 2 dining rooms and 7 of 10 resident rooms. Floors were sticky, handrails were missing or loose, doorframes had missing paint, bathrooms and sinks were dirty, and debris was on resident room floors. (Room 13, Room 9, First Floor Hall, Second Floor Hall, Room 35, Second Floor Shower Room, Room 33, Room 23, Room 25, Room 29, Second Floor Dining Room) Findings include: 1. On 5/19/22 at 9:25 A.M., Room 13's bathroom was observed with the drywall cracked and coming loose around the vent in the ceiling. On 5/19/22 at 2:27 P.M., the same was observed. 2. […]