Catholic Memorial Home

In the surveyor’s words

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

• Actual harm, patternF600Mar 26, 2024

  Based on interviews, record review, and policy review, the facility failed to prevent one Resident (#193), who had a history of agitation, aggression, and physical abuse of staff, from punching four Residents (#147, #83, #122, and #192), who had severe cognitive impairment, from a total sample of 38 residents. 1. On 2/13/24, Resident #193 punched Resident #147; 2. On 3/16/24 and 3/20/24, Resident #193 punched Resident #83; 3. On 3/16/24 and 3/20/24, Resident #193 punched Resident #192; and 4. […]

• Actual harm, patternF607Mar 26, 2024

  Based on interviews, record reviews, and policy review, the facility failed to implement their abuse policy for prevention, protection and reporting to the Department of Public Health (DPH) for four Residents (#147, #83, #192, and #122), out of a total sample of 38 residents. Specifically, the facility failed to implement their policy: 1. For Resident #147, when he/she was struck by a peer on [DATE]. 2. For Resident #83, when he/she was struck by a peer on [DATE] and [DATE]. 3. For Resident #192, when he/she was struck by a peer on [DATE] and [DATE]. 4. For Resident #122, when he/she was struck by a peer on [DATE]. […]

• Actual harm, patternF610Mar 26, 2024

  Based on interviews and record reviews, the facility failed to implement protective interventions to prevent further instances of abuse, resulting in psychosocial distress for four cognitively impaired Residents (#147, #83, #122, and #192), in a total sample of 38 residents. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, by another person. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised ,d+[DATE], indicated but was not limited to: Procedure: -Abuse is defined as, but not limited to, willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. […]

• Actual harm, isolatedF656Oct 14, 2025

  Based on records reviewed, and interviews for one of three sampled residents (Resident #1), who was at risk for falls, had severe cognitive impairment, and whose plan of care indicated he/she required continual supervision while ambulating, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions, when 09/19/25 sometime around 7:15 P.M. Resident #1 ambulated off of his/her unit undetected by staff, walked to the main entrance where he/she opened the main entrance door and fell. Resident #1 was transferred to the Hospital's Emergency Department (ED) for evaluation and was diagnosed with a pelvic fracture. […]

• Actual harm, isolatedF689Oct 14, 2025

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was at risk for falls, had been exhibiting exit seeking behaviors, was at increased risk for elopement, poor safety awareness and required continual supervision by staff while ambulating, the Facility failed to ensure he/she was provided with the necessary level of staff supervision to prevent an incident resulting in injury, when on 09/19/25 sometime around 7:15 P.M., Resident #1 ambulated off of his/her unit undetected by staff, and walked to the Facility's main entrance where he/she opened the main entrance door and fell. Resident #1 was transferred to the Hospital's Emergency Department (ED) for evaluation and was diagnosed with a pelvic fracture. […]