Inspection Report Summary
The most recent inspection on October 31, 2024, found the facility in compliance with fire safety and licensure requirements with no deficiencies noted. Earlier inspections showed a pattern of deficiencies primarily related to life safety code issues such as door locks, fire alarm inaccuracies, and improper use of power strips, as well as resident care concerns including medication errors, incomplete assessments, and infection control during medication administration. Complaint investigations mostly resulted in no deficiencies, though one substantiated complaint cited improper colostomy care involving the use of duct tape, and another noted delayed reporting of an abuse allegation without enforcement actions. Enforcement actions such as fines or license suspensions were not listed in the available reports. The trend suggests improvement in life safety compliance with the most recent survey showing no deficiencies after prior issues.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
18.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
345% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
95% occupied
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 62
Capacity: 65
Deficiencies: 0
Oct 31, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/24/24 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with the Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The building is fully sprinklered except for the generator building and greenhouse.
Report Facts
Facility capacity: 65
Census: 62
Inspection Report
Life Safety
Census: 63
Capacity: 65
Deficiencies: 6
Sep 24, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included issues with bathroom door locks not unlocking from both sides, a kitchen corridor door held open improperly, fire alarm system date/time inaccuracies, ceiling penetrations affecting sprinkler operation, unprotected smoke barrier wall penetrations, and improper use of power strips as fixed wiring substitutes.
Severity Breakdown
SS=E: 5
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 3 shared bathrooms had locks that could be unlocked from both sides in case of emergency. | SS=E |
| Corridor door to kitchen was held open with a bungee cord, impeding self-closing device. | SS=E |
| Fire alarm system did not have accurate time and date information. | SS=F |
| Ceiling penetrations in basement janitor's closet, auditorium, and PPE closet affecting sprinkler system operation. | SS=E |
| Penetrations through smoke barrier wall near Pepsi vending machine not protected to maintain smoke resistance. | SS=E |
| Power strips used as substitute for fixed wiring in business manager's office. | SS=E |
Report Facts
Certified beds capacity: 65
Census: 63
Bathroom doors with deficient locks: 3
Penetrations in ceiling: 5
Smoke barrier wall penetrations: 1
Staff potentially affected by power strip use: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Allision Betz | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Annual Inspection
Census: 64
Capacity: 64
Deficiencies: 7
Sep 13, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 9 to 13, 2024.
Findings
The facility was found deficient in multiple areas including failure to notify physician and resident representative of changes in condition, inaccurate MDS assessments, incomplete diabetes assessments, inadequate fall risk assessments and follow-up, failure to monitor side effects of psychotropic medications, medication errors including wrong insulin administration, and infection control breaches during medication administration and care.
Severity Breakdown
SS=D: 6
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure physician and resident representative were notified of a change in condition for 1 of 4 residents reviewed for falls. | SS=D |
| Failed to ensure accuracy of MDS Assessments for 1 of 1 resident assessments reviewed and 2 of 5 unnecessary medications reviewed. | SS=D |
| Failed to ensure comprehensive assessments were completed for 1 of 12 residents reviewed with diabetes; follow-up assessment after low blood sugar was not completed. | SS=D |
| Failed to ensure comprehensive assessments were completed appropriately for 2 of 5 residents reviewed for accidents; fall risk assessments were incomplete and 72 hour follow-up was not initiated timely. | SS=D |
| Failed to monitor for side effects related to antipsychotic drug use for 1 of 1 resident reviewed for psychotropic drug use. | SS=D |
| Failed to ensure residents were free from significant medication errors; a resident received a dose of the wrong insulin. | SS=D |
| Failed to ensure a safe, sanitary, and comfortable environment to prevent infection transmission; staff did not perform adequate hand hygiene, did not change gloves appropriately, and touched resident pills with bare hands during medication administration. | SS=E |
Report Facts
Survey dates: 5
Census: 64
Total Capacity: 64
Residents reviewed for diabetes: 12
Residents reviewed for accidents: 5
Residents reviewed for psychotropic drug use: 1
Residents reviewed for medication administration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Allision Betz | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 6 | Interviewed regarding notification of change and medication administration | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including notification of change, fall risk assessments, medication errors, and infection control |
| Administrator | Interviewed regarding facility policies and practices | |
| RN 15 | Registered Nurse | Observed medication administration with hand hygiene deficiencies |
| RN 23 | Registered Nurse | Observed medication administration with hand hygiene deficiencies |
| LPN 14 | Licensed Practical Nurse | Observed wound care with hand hygiene deficiencies |
| CNA 7 | Certified Nurse Aide | Observed resident transfer with inadequate hand hygiene |
Inspection Report
Renewal
Deficiencies: 0
Sep 13, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure survey completed on September 13, 2024.
Findings
Cathedral Health Care Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 61
Capacity: 61
Deficiencies: 1
Aug 23, 2024
Visit Reason
This visit was conducted for the investigation of complaint IN00440005 regarding federal and state deficiencies related to colostomy care.
Findings
The facility failed to uphold professional standards of colostomy care for one resident (Resident D) whose colostomy bag was improperly adhered with duct tape during transport to a hospital. Observations and interviews confirmed inappropriate use of duct tape instead of medical-grade adhesives, and the resident exhibited behaviors of removing the colostomy bag, leading to exposure and hygiene concerns.
Complaint Details
Complaint IN00440005 was substantiated with federal and state deficiencies cited related to colostomy care.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide colostomy care consistent with professional standards, including improper use of duct tape to secure colostomy bag during transport. | SS=D |
Report Facts
Census: 61
Total Capacity: 61
Medicare Residents: 1
Medicaid Residents: 59
Other Payor Residents: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in progress notes related to Resident D's behavior and colostomy care incident | |
| Facility Administrator | Interviewed regarding use of duct tape and facility policy on colostomy care | |
| LPN 2 | Interviewed about colostomy bag adherence and use of Skin-Prep barrier wipes | |
| LPN 4 | Observed assisting Resident D with colostomy care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 23, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00440005 survey completed on August 23, 2024.
Findings
Cathedral Health Care Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00440005; paper compliance review found the facility in compliance.
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 0
Jul 2, 2024
Visit Reason
This visit was conducted for the investigation of two complaints, IN00435627 and IN00437682.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00435627 and Complaint IN00437682 were investigated with no deficiencies found related to the allegations.
Report Facts
Census Bed Type: 62
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 58
Census Payor Type - Other: 1
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 1
Jan 9, 2024
Visit Reason
This visit was conducted for the investigation of complaint IN00425501 regarding allegations of abuse at the facility.
Findings
The facility failed to ensure timely reporting of an allegation of abuse for one allegation reviewed involving Resident D. The allegation was investigated but found unsubstantiated. Corrective actions included reporting the allegation during the survey and providing staff in-service on abuse reporting.
Complaint Details
Complaint IN00425501 involved an allegation of physical abuse by a CNA to Resident D. The resident reported being physically abused approximately two months prior, with bruising noted. The facility investigated but was unable to substantiate the allegation. The allegation was not reported to the State Survey Agency within the required timeframe.
Severity Breakdown
F609 D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure timely reporting of an allegation of abuse for 1 of 1 allegations reviewed. | F609 D |
Report Facts
Census: 54
Total Capacity: 54
Resident Interviews: 5
Resident Interviews: 5
Monitoring Duration: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Allision Betz | HFA | Facility representative who signed the report |
| CNA 4 | Named in allegation of physical abuse to Resident D | |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse allegation and investigation |
| Facility Administrator | Facility Administrator | Interviewed regarding awareness of abuse allegation and reporting |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 9, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00425501.
Findings
Cathedral Health Care Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the complaint investigation.
Complaint Details
Investigation of Complaint IN00425501; facility found in compliance.
Inspection Report
Re-Inspection
Census: 50
Capacity: 65
Deficiencies: 0
Dec 4, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 10/02/23.
Findings
At this PSR, Cathedral Health Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for a generator building and a greenhouse.
Report Facts
Facility capacity: 65
Census: 50
Inspection Report
Renewal
Deficiencies: 0
Nov 15, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Recertification and State Licensure of Cathedral Health Care Center.
Findings
Cathedral Health Care Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for Recertification and State licensure.
Inspection Report
Routine
Census: 52
Capacity: 65
Deficiencies: 20
Oct 2, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including emergency preparedness, fire safety, and facility operations.
Findings
The facility was found not in compliance with several emergency preparedness requirements including failure to annually review and update emergency plans, policies, communication plans, and training. Life safety deficiencies included obstructed egress corridors, improperly posted exit door codes, elevated keypad placement, heavy force required to open exit door, combustible storage in egress corridor, improper use of power strips, incomplete fire door inspections, and ventilation issues in oxygen storage room.
Severity Breakdown
SS=F: 11
SS=E: 4
SS=C: 4
SS=B: 2
Deficiencies (20)
| Description | Severity |
|---|---|
| Emergency preparedness plan not reviewed and updated annually. | SS=F |
| Emergency preparedness policies and procedures not reviewed and updated annually. | SS=F |
| Emergency preparedness policies failed to include subsistence needs for staff and residents. | SS=C |
| Emergency preparedness policies failed to include safe evacuation information. | SS=C |
| Emergency preparedness policies failed to include arrangements with other facilities for resident transfer. | SS=C |
| Emergency preparedness communication plan not reviewed and updated annually. | SS=F |
| Emergency preparedness training and testing program not reviewed and updated annually. | SS=F |
| Means of egress corridor obstructed by chair not secured to wall or floor. | SS=B |
| Exit doors had incorrect door release codes posted and keypad code not posted at west stairway door. | SS=F |
| Access-controlled keypad located above required height (6 feet instead of max 48 inches). | SS=F |
| Exit door required heavy force to open despite code entry and magnetic lock release. | SS=F |
| Combustible storage in basement egress corridor including cardboard boxes, furniture, pallets. | SS=F |
| Lack of staff instruction on proper use of UL 300 hood fire suppression system in kitchen. | SS=E |
| Battery backup emergency light in generator enclosure failed to illuminate. | SS=C |
| Corridor doors held open with wedges preventing proper closing. | SS=B |
| Smoke barrier doors did not close completely leaving 1/4 to 1/2 inch gap. | SS=E |
| Firefighter recall testing documentation did not separately document two elevators. | SS=C |
| Power strips used as substitute for fixed wiring in staff areas. | SS=E |
| Oxygen storage/transfilling room exhaust vented into egress corridor instead of outside. | SS=E |
| Incomplete annual inspection and testing documentation for stairway fire door assemblies and oxygen transfilling room door. | SS=F |
Report Facts
Facility capacity: 65
Census: 52
Fire extinguishers not inspected monthly: 3
Stairway fire door assemblies: 8
Smoke barrier doors: 4
Elevators: 2
Exit doors: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and acknowledged multiple deficiencies including emergency preparedness plan, fire safety issues, and corrective actions | |
| Kitchen Staff #1 | Head Cook | Interviewed about UL 300 hood fire suppression system knowledge |
Inspection Report
Routine
Census: 52
Capacity: 65
Deficiencies: 21
Oct 2, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including emergency preparedness, fire safety, and facility operations.
Findings
The facility was found not in compliance with several emergency preparedness requirements including failure to annually review and update emergency plans, policies, communication plans, and training. Life safety deficiencies included obstructed egress corridors, improperly posted exit door codes, elevated keypad placement, heavy force required to open exit doors, non-functioning emergency lighting, combustible storage in egress corridors, improper kitchen staff training on fire suppression, power strips used improperly, incomplete fire door inspections, and inadequate oxygen room ventilation.
Severity Breakdown
SS=F: 9
SS=E: 5
SS=C: 4
SS=B: 3
Deficiencies (21)
| Description | Severity |
|---|---|
| Emergency preparedness plan not reviewed and updated annually. | SS=F |
| Emergency preparedness policies and procedures not reviewed and updated annually. | SS=F |
| Emergency preparedness policies failed to include subsistence needs for staff and residents. | SS=C |
| Emergency preparedness policies failed to include safe evacuation procedures and communication. | SS=C |
| Emergency preparedness policies failed to include arrangements with other facilities for resident transfer. | SS=C |
| Emergency preparedness communication plan not reviewed and updated annually. | SS=F |
| Emergency preparedness training and testing program not reviewed and updated annually. | SS=F |
| Means of egress corridor obstructed by chair not secured to wall or floor. | SS=B |
| Exit doors had incorrect door release codes posted and keypad code not posted. | SS=F |
| Access-controlled keypad located above required height (6 feet instead of 40-48 inches). | SS=F |
| Exit door required heavy force to open despite code entry and magnetic lock release. | SS=F |
| One of two battery backup emergency light sets in generator enclosure did not illuminate when tested. | SS=C |
| Combustible storage in basement egress corridor including cardboard boxes, furniture, and pallets. | SS=F |
| Fire department connection signage missing at front of building. | SS=F |
| Portable fire extinguishers in three staff areas not inspected monthly for two months. | SS=E |
| Two corridor doors held open with wedges preventing proper closing. | SS=B |
| One set of smoke barrier doors did not close completely, leaving a 1/4 to 1/2 inch gap. | SS=E |
| Firefighter recall testing documentation did not separately document two elevators. | SS=C |
| Power strips used improperly as substitute for fixed wiring in three staff areas. | SS=E |
| Kitchen staff not properly trained on use of UL 300 hood fire suppression system. | SS=E |
| Oxygen storage/transfilling room exhaust vented into egress corridor instead of outside. | SS=E |
Report Facts
Facility capacity: 65
Census: 52
Fire extinguishers not inspected monthly: 3
Stairway fire door assemblies: 8
Smoke barrier doors: 4
Elevators: 2
Battery backup emergency light sets: 2
Exit doors: 13
Corridor doors held open: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and acknowledged multiple deficiencies including emergency plan updates, door issues, fire extinguisher inspections, and oxygen room ventilation | |
| Kitchen Staff #1 | Head Cook | Interviewed about knowledge of UL 300 hood fire suppression system use |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 0
Jun 12, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00410057.
Findings
No deficiencies were cited related to the complaint allegation. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00410057 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Census: 46
Total Capacity: 46
Payor Type Census: 1
Payor Type Census: 41
Payor Type Census: 4
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 0
Apr 10, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00401774.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00401774 found no deficiencies related to the allegations.
Report Facts
Census: 49
Total Capacity: 49
Medicaid Census: 44
Other Payor Census: 5
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Feb 13, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00400559.
Findings
The complaint IN00400559 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00400559 was investigated and found unsubstantiated due to lack of evidence.
Report Facts
Census: 50
Total Capacity: 50
Medicare Census: 3
Medicaid Census: 41
Other Payor Census: 6
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 0
Oct 26, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00389110 and IN00381841.
Findings
Complaint IN00389110 was unsubstantiated due to lack of evidence. Complaint IN00381841 was substantiated but no deficiencies were cited related to the allegation. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00389110: Unsubstantiated due to lack of evidence. Complaint IN00381841: Substantiated with no deficiencies cited related to the allegation.
Report Facts
Census Bed Type: 46
Census Payor Type Medicaid: 40
Census Payor Type Other: 6
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