Catholic Eldercare on Main

In the surveyor’s words

From the most serious findings on record at Catholic Eldercare on Main, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 18, 2024

  Based on observation, interview and document review, the facility failed to comprehensively reassess and, if needed, develop interventions with unsupervised eating to reduce the risk of accidental choking or asphyxiation for 1 of 1 resident (R67) who ate unsupervised in their room and had two documented episodes of choking. This constituted an immediate jeopardy (IJ) situation for R67. The IJ began on 9/14/24 when R67 choked for a second time on oral food, and the facility failed to comprehensively reassess R67's risk of choking, implement any interventions for increased supervision while eating or safe swallowing (i.e., speech therapy), or reeducate R67 and her responsible party on the risks of choking if R67 remained eating unsupervised as she had been despite choking. […]

• Immediate jeopardy, isolatedF684Sep 29, 2021

  Based on interview and document review, the facility failed to ensure staff obtained a blood pressure or provided a full assessment to identify a change in condition for 1 of 2 residents (R1) reviewed for quality of care. R1 had a change in condition that staff were monitoring on [DATE]; however, when staff attempted to obtain a blood pressure with a machine on three different occasions, the machine did not register the resident's blood pressure due to movement and staff did not attempt an alternative to obtain a blood pressure. The survey resulted in immediate jeopardy (IJ) to resident safety as R1 was sent to the hospital on [DATE] and died . The IJ began on [DATE]. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 12:59 p.m. […]

• Actual harm, isolatedF580Sep 29, 2021

  Based on interview and document review, the failed to timely notify the physician of a change of condition for 1 of 2 residents (R1) reviewed for change of condition. R1 was unable to swallow her food, staring blankly, had an increase in pulse rate. The following shift R1 had a decrease in pulse rate, and on both shifts staff were unable to obtain a blood pressure. R1 sustained harm as required emergency services and expired at the hospital. Findings include: R1's facesheet printed on [DATE], noted R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], noted R1 had poor cognition and required extensive assistance with dressing, bed mobility, and was totally dependent on staff for transfers. […]

• No harm, potential for more than minimal, widespreadF880Oct 18, 2024

  Based on observation, interview, and document review the facility failed to ensure residents clothing was covered during storage and delivery to the residents. The uncovered linen had the potential to affect all residents. Findings include: During observation and interview on 10/14/24 at 1:13 p.m. laundry aide (H)-C was observed pushing a large metal uncovered laundry cart down a resident hallway on the first floor containing various cleaned resident clothing items. H-C stated she had worked at the facility as a laundry aide for a long time and they had never covered the personal laundry carts. During observation and interview on 10/15/24 at 1:28 p.m. H-A verified she was delivering cleaned personal linen on the second floor in an uncovered cart. […]

• No harm, potential for more than minimal, widespreadF880Aug 18, 2022

  Based on observation, interview and document review, the facility failed to implement the Centers for Disease Control and Prevention (CDC) guidance for individualized transmission-based precautions including the use, handling, and disposal of appropriate personal protective equipment (PPE), and failed to provide isolation precautions to prevent the spread of COVID-19 for two of two residents who were positive for COVID-19 (R144, R77). This had the potential to affect all residents and staff who were at risk of infection, or re-infection, from COVID-19 and all 155 residents due to potentially related staff illness. Further, the facility failed to ensure food was protected from pathogens during transportation to residents from the kitchen. […]