Inspection Reports for
Cathedral Health Care Center

The facility failed to develop and implement comprehensive, person-centered care plans for three residents taking anticonvulsant, anticoagulant, and diuretic medications. The clinical records lacked care plans for these medications despite residents routinely receiving them.

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.

The facility was found deficient in multiple areas including failure to notify physicians and representatives of resident condition changes, inaccurate Minimum Data Set (MDS) assessments, incomplete fall risk assessments and follow-ups, medication errors including incorrect insulin administration, inadequate monitoring of antipsychotic side effects, and poor infection control practices such as insufficient hand hygiene.

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.

Complaint IN00440005 was substantiated with federal and state deficiencies cited related to colostomy care.

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.

The citation relates to complaint IN00440005. The complaint involved concerns about the use of duct tape on a resident's colostomy bag and the facility's failure to provide proper colostomy care.

The facility failed to provide appropriate colostomy care for one resident, including the inappropriate use of duct tape to secure the colostomy bag during transport to a hospital. Observations and interviews confirmed the resident frequently removed the colostomy bag, and the facility lacked proper means to secure it.

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.

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.

This citation relates to complaint IN00425501. The allegation involved Resident D reporting physical abuse by CNA 4, which was not reported timely to the State Survey Agency. The facility's investigation was unable to substantiate the allegation.

The facility failed to ensure timely reporting of an allegation of abuse for one resident. The investigation found that the resident reported physical abuse by a CNA, but the facility did not report the incident to the State Survey Agency within the required timeframe.

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.

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.

The facility had multiple deficiencies including failure to deliver mail on Saturdays, inaccurate resident assessments, failure to provide appropriate treatment such as sliding scale insulin, inadequate catheter care leading to recurrent urinary tract infections and hospitalizations, improper storage of controlled substances, unsafe food handling and storage practices, and lapses in infection control practices such as failure to change gloves between tasks.