St Catherines Living Center

In the surveyor’s words

From the most serious findings on record at St Catherines Living Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 26, 2024

  Based on review of the facility reported incident (FRI) and investigation reports, record review, review of facility policy, and staff and resident interviews, the facility failed to provide an environment free of verbal abuse for 1 of 1 sampled resident (Resident #19) with an allegation of abuse. Failure to identify abuse and ensure residents are free from verbal abuse and abusive gestured language, which includes disparaging and derogatory terms caused fear, anxiety, mental anguish, and psychosocial harm. During the on-site recertification survey and FRI investigation, the team consulted with the State Survey Agency (SSA) on 11/21/24 at 8:44 a.m. and determined an immediate jeopardy (IJ) situation existed on 10/21/24. […]

• Actual harm, isolatedF600Jan 28, 2026

  Based on record review, review of the facility reported incident (FRI) and investigation, and review of facility policy, the facility failed to ensure residents remained free from abuse for 1 of 1 closed record (Resident #51) who displayed physical behaviors towards another resident. Failure to protect residents from physical abuse resulted in injury and pain. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.Findings include: Review of the facility policy titled Abuse Prevention Plan occurred on 01/29/26. This policy, dated year 2017, stated, . In order to prevent abuse . the facility shall do the following . Identify, correct, and intervene in situations where abuse . occurs. […]

• Actual harm, isolatedF684Mar 11, 2025

  Based on record review, review of facility policies, and staff interview, the facility failed to provide the necessary care and treatment for 1 of 2 sampled residents (Resident #2) with impaired skin integrity of the feet/toes. Failure to assess, monitor, and treat skin issues in a timely manner resulted in a delay of treatment and contributed to Resident #2's hospitalization for amputation of fourth and fifth toes. Findings include: Review of the facility policy titled Prevention and Treatment of Skin Breakdown occurred on 03/11/25. This policy, dated 09/01/18, stated, . Skin integrity is monitored and abnormal findings are documented: Skin is observed daily with cares. Review of the facility policy titled Change in Condition occurred on 03/11/25. This policy, revised 10/02/23, stated, . […]

• No harm, potential for more than minimal, patternF812Jan 28, 2026

  Based on observation and review of professional reference, the facility failed to maintain a clean and sanitary kitchen for 2 of 2 kitchens (North Kitchen and South Kitchen). Failure to ensure tableware is placed on resident meal trays in a sanitary manner and ensure floors, cabinets, and the warewashing machine are free from food, dust, and mineralization debris has the potential for contamination of dishware/food and may result in foodborne illness to residents, staff, and visitors. Findings include:The 2022 Food and Drug Administration (FDA) Food Code, Section 4-904.13, page 455, stated, The presentation or setting of . cleaned and sanitized utensils shall be done in a manner designed to prevent the contamination of food- and lip-contact surfaces. […]

• No harm, potential for more than minimal, patternF880Jun 16, 2021

  THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 12/03/20. Based on observation, review of facility policy/procedure, and staff interview, the facility failed to follow infection control practices for 5 of 14 sampled residents (Resident #7, #9, #11, #28 and #94) and 2 supplemental residents (Resident #31 and #38). Failure to practice infection control related to hand hygiene and glove use during cares (Resident #7, #9, #11, #28, #31, and #94), and during meal service/feeding (Resident #38) has the potential for transmission of communicable diseases and infections to residents and staff. Findings include: Review of the facility policy titled Hand Hygiene occurred on 06/16/21. […]