Cathedral Village

Inspectors wroteBased on review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to provide each resident with adequate supervision and assistance devices to prevent accidents related to transfer assistance for two of four residents reviewed (Resident R1 and R2). This deficiency was identified as past non-compliance.

Inspectors wroteBased on review of clinical documentation and interviews with staff, it was determined that the facility did not ensure that one resident was free from accidents and hazards related to inappropriate transfers for one of five residents reviewed. This deficiency is cited as past non-compliance. (Resident R1)

Inspectors wroteBased on review of policy, review of clinical records and review of facility provided documentation, it was determined that facility did not ensure to complete a thorough investigation for two of 18 residents reviewed regarding facility reported incidents (Resident R42, R2)Review of facility policy 'Falls management program,' indicates that when a resident sustains a fall, the assessment process will include an investigation using the Fall investigation analysis sheet. This is to help identify the root cause and whether or not the fall was avoidable or unavoidable. Review of Resident R42 clinical record revealed medical diagnosis of Alzheimer's disease, pain in bilateral knees, osteoarthritis, long-term use of insulin. Review of physical therapy discharge recommendations, completed on March 20, 2025, indicate that R42 is to continue to walk and stand with supervision. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to implement care plan interventions to meet resident needs for one of three residents reviewed (Resident R1). This deficiency was identified as past non-compliance. Based on review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to implement care plan interventions to meet resident needs for one of three residents reviewed (Resident R1). This deficiency was identified as past non-compliance. Findings Include:Review of facility policy Care Planning review 01/07/2026 revealed the facility will comprehensively evaluate and re-evaluate a resident's need for service and develop a plan to promote their highest practicable level of functioning. [...]

Inspectors wroteBased on review of clinical records, facility documentation, and staff statements, it was determined that the facility failed to provide assistance with activities of daily living related to nutrition, incontinence care, and positioning for five residents reviewed. (Resident R1, R2, R3, R4, and R5). This was identified as past non-compliance. Findings Include: Review of Resident R1's clinical record revealed a quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 2, 2025, indicated diagnoses including progressive neurological conditions, dementia (loss of cognitive functioning), Parkinson's disease (neurovegetative disorder that affects movement), paralytic gait (difficulty initiating movement), and dysphasia (language disorder); and had a BIMS score of six, indicating cognitive impairment. [...]

Inspectors wroteNumber of residents sampled: n/aNumber of residents cited: n/a the facility did not ensure food was stored, prepared, and served in accordance with professional standards of practice Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety.

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to conduct a complete and thorough investigation to rule out an allegation of neglect for one of four residents reviewed (Resident R4). Findings Include: Review of facility policy Abuse Neglect or Exploitation reviewed July 2, 2025, revealed neglect is the failure of the facility, or its employees, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress to the resident despite knowledge that the care and services were required. [...]

Inspectors wroteNumber of residents sampled: 3Number of residents cited: 2the facility did not ensure a medication error rate of < 5%Based on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for two of three residents observed during medication administration (Residents R32, and R67).

Inspectors wroteBased on observation, interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders for two of three residents observed during medication administration observed, resulting in a significant medication error (Residents R32, and R67). Based on observation, interview, and clinical record review, it was determined that the facility failed to correctly administer medications in accordance with physician orders for two of three residents observed during medication administration observed, resulting in a significant medication error (Residents R32, and R67).

Inspectors wroteBased on staff interviews, review of clinical records, facility documentation, and facility policy, it was determined the facility failed to ensure one of four residents reviewed was free of neglect, (Resident R1). This failure resulted in actual harm to Resident R1 who was not provided care by two nurse aides while experiencing a combative episode. Resident R1 grabbed onto nurse aide, who moved resident's arm, resulting in a fracture of the right humerus (arm).

Inspectors wroteBased on observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly.

Inspectors wroteBased on observation, interviews with residents, interviews with staff, review of facility documentation and clinical records, the facility failed to ensure each resident's dignity was maintained regarding cell phone use of staff, for one out of 24 residents reviewed. (R50).

Inspectors wroteBased on review of facility policies and documentation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a resident remained free from verbal abuse, which resulted in emotional distress for one of 24 residents reviewed. (Resident R38)

Inspectors wroteBased on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of 24 residents reviewed (R38).

Inspectors wroteBased on observations, review of clinical records, and interviews with facility staff, it was determined that the facility failed to ensure that it was free of medication error rate of five percent or greater for one of six residents observed during medication administration (Resident R51).

Inspectors wroteBased on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related appropriate cleaning techniques for medical equipment, on three of the six Medication Administration Reviews.

Inspectors wroteBased on the review of facility documentation, review of clinical records, and interviews with resident and staff, it was determined the facility failed to monitor the temperature of a hot liquid before being served to a resident. This failure resulted in actual harm to Resident R1 who spilled hot water and sustained a second degree burn on the forearm for one of two resident records reviewed (Resident R1).