Inspection Reports for Cathedral Village

The complaint investigation found substantiated neglect involving Nurse Assistant Employee E4 sleeping on duty, resulting in inadequate care for residents R1, R2, R3, R4, and R5. The alleged perpetrator was placed on administrative leave during the investigation. Corrective actions included skin assessments, interviews, staff re-education, audits, and notifications to relevant authorities.

The facility failed to provide adequate care and assistance to five residents, resulting in residents being unkempt, soiled, and uncomfortable, with risks for skin breakdown, infection, and decreased dignity. Nurse Assistant Employee E4 was observed sleeping during a shift, contributing to neglect. The deficiency was cited as past non-compliance and corrective actions were initiated.

The inspection identified multiple deficiencies related to criminal background checks, food storage, staff training, medication records and storage, medication administration documentation, support plan documentation, and resident record content. All deficiencies had plans of correction accepted and were reported as fully implemented by 09/11/2025.

The complaint investigation focused on an allegation of neglect where a resident was found on the bathroom floor after no staff responded to their call for assistance. The facility failed to conduct a complete investigation or have an incident report related to this allegation.

The facility failed to conduct a thorough investigation of neglect allegations for one resident found on the bathroom floor. Additionally, medication errors were identified involving incorrect dosages and crushing medications against physician orders for two residents, resulting in an 11.54% medication error rate. The facility also failed to properly label and date food items, compromising food safety standards.

The complaint was substantiated due to the facility's failure to provide two staff members during incontinence care for Resident R1, who displayed combative behaviors. This failure resulted in actual harm to the resident. Nurse aide Employee E3 was terminated from employment on June 9, 2025.

The facility failed to ensure that two staff members provided care to Resident R1 during a combative episode, resulting in actual harm when the resident sustained a fracture of the right humerus. The allegation of neglect was substantiated, and the nurse aide involved was terminated.

The inspection found that the facility had fully implemented the submitted plan of correction addressing deficiencies related to assistance with activities of daily living, treatment of residents with dignity and respect, and accurate documentation of residents' ability to self-administer medications.

The complaint investigation substantiated verbal abuse by Nurse Aide Employee E10 towards Resident R38, resulting in emotional distress. The Nurse Aide was placed on administrative leave and terminated. Emotional support and psychiatric consultation were provided to the resident.

The facility was found deficient in multiple areas including failure to maintain resident dignity regarding staff cell phone use, substantiated verbal abuse by a nurse aide, inappropriate respiratory care with incorrect oxygen administration, medication errors exceeding 5%, improper food storage and sanitation practices, inadequate garbage disposal, and failure to disinfect medical equipment during medication administration.

The complaint investigation found that Resident R1 spilled hot water served by a nursing assistant who was unaware of the water temperature, resulting in a second degree burn. The resident confirmed the incident during an interview, and the facility acknowledged the failure to ensure safe hot water temperatures.

The facility failed to ensure safe hot water temperatures prior to serving Resident R1, resulting in a second degree burn on the resident's right forearm. Interviews and documentation revealed that hot water was served without verifying its temperature, and the facility was in the process of developing a policy on hot beverage temperatures.

The complaint investigation was triggered by a licensure investigation concerning Employee E21, who was found to have provided care as a registered nurse without a valid license, affecting 63 residents. The facility failed to notify residents or representatives of the investigation and failed to conduct a thorough investigation.

The facility failed to ensure that Employee E21 was properly licensed and competent to provide nursing care, resulting in an immediate jeopardy situation affecting 63 residents. Additional deficiencies included failure to update care plans, provide adequate personal hygiene assistance, timely medication administration, safe food temperatures, proper medication storage, infection control practices, and antibiotic stewardship.

The complaint was substantiated. The resident fell out of bed during continence care by Employee E5, nurse aide, who did not turn the resident appropriately. The resident sustained multiple rib fractures and a scalp hematoma. The nurse aide was terminated following the substantiation of neglect.

The facility failed to ensure a resident remained free from neglect, resulting in actual harm including multiple rib fractures and a scalp hematoma. The investigation substantiated neglect by a nurse aide who did not follow proper care procedures, leading to the resident's fall and injury.

The facility was found to have implemented the submitted plan of correction fully. Two deficiencies were noted: failure to conduct fire drills during sleeping hours every six months, and improper documentation of blood glucose readings, both of which were corrected with plans accepted and implemented.

The inspection identified multiple deficiencies including lack of training on memory support, improper storage of medical equipment, limited use of alternate exit routes during fire drills, incomplete medical evaluations, medication storage and administration issues, lack of resident activity programs due to staffing shortages, and incomplete support plans for communication needs.

The facility was found to have fully implemented the plan of correction regarding the submission of a final incident report, which had previously not been submitted. Continued compliance must be maintained.

The submitted plan of correction related to medication administration and glucometer reading documentation was found to be fully implemented. Continued compliance is required.

The facility was found to be in substantial compliance with applicable regulations, but citations were issued related to emergency procedures not including local municipality information. A plan of correction was accepted and implemented.

The inspection found several deficiencies including failure to provide timely refunds to discharged residents, failure to post weekly menus in a conspicuous place, unsecured medications in a resident's room, medication administration errors, and incomplete initial assessments for newly admitted residents. Plans of correction were accepted and implemented.