Cathedral Village

In the surveyor’s words

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

• Immediate jeopardy, patternF726May 2, 2024

  Based on the review of facility documentation, review of personnel records and interviews with staff, it was determined that the facility failed to ensure six of six employees possessed the appropriate skills and competencies to provide nursing and related care and services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Further, review of Employee E21's personnel file revealed that the Employee E21 was an unlicensed staff, who provided care and services as a Registered Nurse, without verifiable educational background and registration as a nurse. […]

• Immediate jeopardy, patternF839May 2, 2024

  Based on the review of facility documentation, review of personal records and interviews with staff, it was determined that the facility failed to ensure that a professional staff possessed required nursing license in accordance with applicable state law. Review of one of six personnel files revealed that Employee E21, who was an unlicensed staff, and provided care as a Registered Nurse, to 63 residents. Employee E21 did not have a verifiable educational background and registration, as a Registered Nurse. This failure resulted in an Immediate Jeopardy situation to 63 residents who received care and services from Employee E21. (Employee E21). Findings Include: Review of the Professional Nursing Law The Act of [DATE] P.L 317, No 69, revealed that Section 3. […]

• Actual harm, isolatedF600Jun 16, 2025

  Based on staff interviews, review of clinical records, facility documentation, and facility policy, it was determined the facility failed to ensure one of four residents reviewed was free of neglect, (Resident R1). This failure resulted in actual harm to Resident R1 who was not provided care by two nurse aides while experiencing a combative episode. Resident R1 grabbed onto nurse aide, who moved resident's arm, resulting in a fracture of the right humerus (arm). Finding includes: Review of the facility policy titled Abuse, Neglect or Exploitation, last dated October 2023, states, That each resident is provided with a safe environment where they are not subject to mental, physical, verbal, and sexual abuse. […]

• Actual harm, isolatedF689Sep 19, 2024

  Based on the review of facility documentation, review of clinical records, and interviews with resident and staff, it was determined the facility failed to monitor the temperature of a hot liquid before being served to a resident. This failure resulted in actual harm to Resident R1 who spilled hot water and sustained a second degree burn on the forearm for one of two resident records reviewed (Resident R1). Findings include: Review of Resident R1's admissions, Minimum Data Set (MDS- assessment of resident needs) dated August 12, 2024, revealed a BIMS (brief interview for mental status) score of 14 which indicated that the resident was cognitively intact. […]

• Actual harm, isolatedF600Apr 26, 2023

  Based on review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident remained free from neglect, which resulted in actual harm to Resident R1 who fell out of bed during continence care and sustained a left fourth posterior rib fracture, a left fifth anterolateral rib fracture and a left parieto-occipital scalp hematoma for one of five residents reviewed. (Resident R1) Findings include: Review of facility policy, Abuse Neglect or Exploitation' dated October 24, 2022, revealed Each resident is provided with a safe environment where they are not subject to mental, physical, verbal and sexual abuse. […]