Catholic Memorial Home

Inspectors wroteBased on records reviewed, and interviews for one of three sampled residents (Resident #1), who was at risk for falls, had severe cognitive impairment, and whose plan of care indicated he/she required continual supervision while ambulating, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions, when 09/19/25 sometime around 7:15 P.M. Resident #1 ambulated off of his/her unit undetected by staff, walked to the main entrance where he/she opened the main entrance door and fell. Resident #1 was transferred to the Hospital's Emergency Department (ED) for evaluation and was diagnosed with a pelvic fracture.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was at risk for falls, had been exhibiting exit seeking behaviors, was at increased risk for elopement, poor safety awareness and required continual supervision by staff while ambulating, the Facility failed to ensure he/she was provided with the necessary level of staff supervision to prevent an incident resulting in injury, when on 09/19/25 sometime around 7:15 P.M., Resident #1 ambulated off of his/her unit undetected by staff, and walked to the Facility's main entrance where he/she opened the main entrance door and fell. Resident #1 was transferred to the Hospital's Emergency Department (ED) for evaluation and was diagnosed with a pelvic fracture.

Inspectors wroteBased on observation and interview, the facility failed to ensure for six residents of a total sample of 35 residents, that the Residents were provided respect and dignity in a manner and environment that promoted enhancement of the residents' quality of life and individuality. Specifically, the facility failed: To provide meal assistance in a respectful and dignified manner on units 1E, 2A, and 7.

Inspectors wroteBased on observations and interviews, the facility failed to follow infection control prevention practices. Specifically, the facility failed to: 1. Ensure effective hand hygiene practices and appropriate PPE (personal protective equipment) were utilized when entering in and out of resident rooms, including residents on transmission based precautions; 2. Ensure staff utilized appropriate PPE while providing direct care to Resident #36 on Enhanced Barrier Precautions; 3. Ensure staff and resident hand hygiene was implemented during meals on Unit 7 and Unit 2A; 4. Ensure that medication carts were maintained in a clean, sanitary condition to prevent contamination and transmission of disease from resident to resident; and 5. Ensure that sanitary practices were used by nursing while preparing and administering medications.

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident's privacy was maintained. Specifically the facility: 1. failed to perform a Brief Interview of Mental Status (BIMS) assessment in a private and confidential space. 2. failed to ensure resident protected health information (PHI) was secure and not visible to others on one nursing unit of seven nursing units.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the person-centered plan of care for one Resident (#173), out of 35 sampled residents. Specifically, the facility failed to implement the fall risk prevention intervention of having the call light within reach.

Inspectors wroteBased on observation and interview, the facility failed to ensure that medications were labeled and stored in accordance with accepted professional principles for two Residents (#144 and #103), of a total sample of 35 residents. Specifically, the facility failed: 1. For Resident #103, to ensure medications were stored in the container with the pharmacy label; and 2. For Resident #144, to ensure that the Resident's topical medications were stored securely.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide adaptive equipment for one Resident (#5), out of a total sample of 35 residents. Specifically, the facility failed to ensure Resident #5 was provided with built-up handles for utensils and a handled cup for beverages during meals.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure food items were properly dated and stored in three of three kitchenettes.

Inspectors wroteBased on record review and interview, the facility failed to ensure a complete and accurate medical record was maintained for one Resident (#36), out of a total sample of 35 residents. Specifically, for Resident #36, the Resident's medical record failed to reflect accurate health care proxy activation status.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to prevent one Resident (#193), who had a history of agitation, aggression, and physical abuse of staff, from punching four Residents (#147, #83, #122, and #192), who had severe cognitive impairment, from a total sample of 38 residents. 1. On 2/13/24, Resident #193 punched Resident #147; 2. On 3/16/24 and 3/20/24, Resident #193 punched Resident #83; 3. On 3/16/24 and 3/20/24, Resident #193 punched Resident #192; and 4. On 3/18/24, Resident #193 punched Resident #122. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, by another person.

Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to implement their abuse policy for prevention, protection and reporting to the Department of Public Health (DPH) for four Residents (#147, #83, #192, and #122), out of a total sample of 38 residents. Specifically, the facility failed to implement their policy: 1. For Resident #147, when he/she was struck by a peer on [DATE]. 2. For Resident #83, when he/she was struck by a peer on [DATE] and [DATE]. 3. For Resident #192, when he/she was struck by a peer on [DATE] and [DATE]. 4. For Resident #122, when he/she was struck by a peer on [DATE]. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, by another person.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement protective interventions to prevent further instances of abuse, resulting in psychosocial distress for four cognitively impaired Residents (#147, #83, #122, and #192), in a total sample of 38 residents. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, by another person.

Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to implement their abuse policy for four Residents (#147, #83, #192 and #122) out of a total sample of 38 residents. Specifically, the facility failed: 1. For Resident #147, to report abuse when he/she was struck by a peer on 2/13/24. 2. For Resident #83, to report abuse when he/she was struck by a peer on 3/16/24 and 3/20/24. 3. For Resident #192, to report abuse when he/she was struck by a peer on 3/16/24 and 3/20/24. 4. For Resident #122, to report abuse when he/she was struck by a peer on 3/18/24. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, by another person.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that necessary behavioral health care and services were provided to create an environment to maintain the highest psychosocial well-being for one Resident (#193), out of a total sample of 38 residents. Specifically, the facility failed to review and revise the behavioral health care plan when interventions were not effective and the Resident had an increase in aggressive behaviors and physical altercations with staff and peers.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required on five of seven units in the facility. Specifically, the facility failed to ensure all medication and treatment carts were locked when unattended and unsupervised.

Inspectors wroteBased on observations, interviews and records reviewed for two Residents (#74 and #103), of 38 sampled residents, the facility failed to maintain professional standards of practice. Specifically, the facility failed to ensure: 1. For Resident #74, heel protection lifts/boots were in place, as ordered by the physician; and 2. For Resident #103, heel protection boots and bilateral hand carrots (orthotic positioning device) were in place, as ordered by the physician.

Inspectors wroteBased on observations, interviews, policy review, and record review, for one Resident (#3), of 38 sampled residents, the facility failed to ensure he/she received care and treatment to promote healing of a pressure injury. Specifically, for Resident #3, the facility failed to assess his/her pressure injury weekly and designate a multidisciplinary skin care team to review the plan of care weekly from 10/25/23 through 1/30/24 resulting in a wound infection requiring hospitalization and intravenous (IV, through a catheter directly into a blood vessel) antibiotics.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure all medications used in the facility were safely and securely stored and labeled in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Properly store controlled drugs in separately locked compartments in three of eight medication carts reviewed; 2. Properly label all medications stored in one of six medication refrigerators and two of eight medication carts; 3. Lock one of seven medication storage cabinets and one of six-unit medication refrigerators when not attended by persons with authorized access; and 4. Store medications at proper temperatures to preserve their integrity for three out of six-unit medication refrigerators and maintain consistent documentation of medication refrigerator temperatures for six out of seven medication refrigerators reviewed.

Inspectors wroteBased on record review, policy review, and staff interviews, the facility failed to ensure that for six Residents (#84, #99, #139, #197, #198, and #65), out of a total sample of 35 residents, that each Resident's drug regimen was free of unnecessary drugs. Specifically, the facility failed a. For Residents #84, #99, #139, and #197 to ensure that an appropriate diagnosis was identified, targeted behaviors/signs and symptoms were monitored to evaluate the effectiveness of psychotropic medication, and/or potential side effects were identified and monitored to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being, per the facility policy; b. For Resident #198, to ensure the PRN (as needed) psychotropic drugs were limited to 14 days; and c. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure that three out of six unit medication refrigerators were maintained in safe operating condition to help preserve the integrity of the medications stored.

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed for one Resident (#100), to ensure the Resident was assessed by the Interdisciplinary Team (IDT) for the self-administration of medications, out of a total sample of 35 residents.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that the right to personal privacy was maintained for one Resident (#154).

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure two Residents (#189 and #203), out of 35 sampled residents, were free from Velcro seat belt restraints.

Inspectors wroteBased on policy review, record review, and interviews, the facility failed to ensure that staff implemented written policies and procedures for allegations of abuse for one Resident (#197), out of 35 sampled residents.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff reported two allegations of verbal abuse within two hours to the Department of Public Health (DPH) for two Residents (#197 and #65), out of a total sample of 35 residents.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff thoroughly investigated and reported the results of an allegation of abuse for two Residents (#197 and #65), out of a total sample of 35 residents. Specifically, the facility failed to: 1. For Resident #197, investigate an allegation of verbal abuse; and 2. For Resident #65, report the results of a completed investigation of resident-to-resident abuse to the Department of Public Health within five days.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure a Physician's order for admission was obtained according to facility policy for two Residents (#211 and #212), out of three closed records reviewed, from a total sample of 35 residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for two Residents (#74 and #71), out of a total of 35 sampled residents. Specifically, the facility failed 1. For Resident #74, to develop and implement the care plan for weekly weights and record percentage of meals consumed, per the physician's orders; and 2. For Resident #71, to implement the care plan and provide mealtime assistance and cueing. 1. Resident #74 was admitted to the facility in October 2021 with diagnoses including Parkinson's disease, dementia with Lewy bodies, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment, dated 4/14/22, indicated Resident #74 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to evaluate for effectiveness and revise the comprehensive care plan for two Residents (#112 and #84), out of a total sample of 35 residents. Specifically, the facility failed 1. For Resident #112, to revise the care plan for the use and monitoring of psychotropic medications; and 2. For Resident #84, to revise the care plan for skin to reflect the Resident's intermittent behavior of removing booties prescribed by the physician as an intervention to prevent to development of pressure injuries to his/heels.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure professional standards of practice were followed for two Residents (#100 and #99), out of a total sample of 35 residents. Specifically, the facility failed: 1. For Resident #100, to ensure nursing staff did not leave medications at the bedside; and 2. For Resident #99, to complete ongoing comprehensive skin assessments.

Inspectors wroteBased on interview and record review, the facility failed to assist one Resident (#85), out of a total sample of 35 residents, in obtaining an alternative or replacement hearing device in a timely manner upon discovering the Resident's hearing aids were lost.

Inspectors wroteBased on interview, observation, and policy review, the facility failed to ensure existing interventions to promote healing and/or prevent worsening of a pressure ulcer and prevent skin breakdown on the heels (air mattress; and bilateral heel off booties and a pillow to offload heels, respectively) were followed for one Resident (#84), out of a total sample of 35 residents.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for one Resident (#99), out of a total sample of 35 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to effectively manage one Resident's (#170) pain, out of a total sample of 35 residents.

Inspectors wroteBased on document review, record review, and staff interview, the facility failed to ensure that for two Residents (#139 and #197), out of a sample of 35 residents, the facility's psychiatric consultant, who provided one to one (1:1) psychotherapy, developed a treatment plan which identified individualized, person-centered, and measurable goals of treatment.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one Resident (#112) with dementia, out of a total sample of 35 residents. Resident #112 was admitted to the facility in January 2022. Review of a Psychiatric Evaluation, 2/23/22, indicated Resident #112 had cognitive impairment and dementia. Review of the clinical record indicated the facility did not address the Resident's diagnosis of dementia until 3/11/22 (2.5 weeks later). Review of Resident #112's Care Plan for Mood/Behaviors, Episodes of: yelling, screaming, swearing, crying, or hitting staff or my peers, included the following interventions: -Administer medications as ordered, monitor and record effectiveness. Report adverse side effects. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure medication irregularities identified during the Pharmacist's Drug Regimen Review were reported and acted upon for one Resident (#198), out of a total sample of 35 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to monitor for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-coagulant agent prescribed for four Residents (#59, #99 #139, and #173), out of a total sample of 35 residents.

Inspectors wroteBased on record review and interviews, the facility failed to develop an integrated, person-centered hospice care plan identifying coordination of care between the facility and the hospice provider for one Resident (#185), out of a total sample of 35 residents.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure standards of infection prevention practices were maintained during a dressing change for one Resident (#74), out of a total sample of 35 residents.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to implement their Antibiotic Stewardship Program policy to ensure that a stop date or a clinical rationale for continued use was included in the order for one Resident (#198), out of a total sample of 35 residents, being prescribed an antibiotic.