Katherine Healthcare

Inspectors wroteBased on interview and record review, the facility failed to complete the nutritional initial screener (NIS) for seven of eight residents (Resident 1, 2, 4, 5, 6, 7, and 8) upon admission. This failure had the potential for residents nutritional needs being unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of three resident (Resident 1) from misappropriation of property (unauthorized use of someone else's property) when Resident 1's controlled medication (medications that are regulated due to higher risk of misuse) Lorazepam (used to treat severe anxiety) with 19 tablets were missing or unable to be located. This failure resulted in Resident 1 missing two doses of the medication and potential adverse health outcomes and violated patient rights. During an interview with Registered Nurse (RN) A, on 12/2/25 at 1:30 p.m., RN A stated he was counting the narcotics (used to treat moderate to severe pain) in the Station 2 medication cart with the night shift nurse (RN B) on 11/30/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the needs of one of three residents (Resident 1) when there was no accurate accountability of the controlled medication (medication that can be easily abused and are under strict government control) lorazepam 0.5 milligram (mg, unit of measurement) tablet. This failure resulted in Resident 1 not receiving two doses of the controlled medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its Policy and Procedures regarding oxygen administration for two out of six sampled residents (Resident 43 and Resident 3) when:1. No oxygen (O2: a colorless, odorless and tasteless gas, essential for life) administration order for Resident 43;2. O2 humidifier(a device, often a bottle contains water that adds moisture to dry supplemental O2 use) not adequately replaced for Resident 43;3. No O2 administration order, unlabeled oxygen tubing, and no oxygen in use sign posted for Resident 3;4. No care plan for O2 administration for Resident 3. These failures had the potential to affect sampled residents medical condition, well-being, and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 out of 14 sampled residents (Resident 35, Resident 53, and Resident 3) were free from unnecessary medications when:1. Resident 35 received calcium acetate (brand name: Phoslo; medication to treat high phosphate [phosphorous] in the blood, in patients with end-stage renal disease [ESRD, a condition when the kidneys no longer function well enough to meet the body's needs]) for a wrong indication and not given with mealtimes as in accordance with the manufacturer's specifications. This resulted in inadequate indication and ineffective use of the medication to treat/prevent high phosphorous level.2. Resident 53 had an as-needed order for milk of magnesia (product containing magnesium, to treat constipation), a medication to avoid in residents that have ESRD. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that infection control practices were implemented when: 1. Unlabeled personal care items; 2. Uncovered BiPAP (bilevel positive airway pressure, a machine used to help breathe by providing two different levels of air pressure through a mask) face mask; 3. No appropriate receptacle (a container to hold or store things) in room with contact precautions (CP: infection control measures used to prevent the spread of germs between residents) to discard used personal protective equipment (PPE: equipment worn to minimize exposure to infections and illnesses); 4. Cloudy urine in foley catheter (F/C: a thin, flexible tube inserted into the bladder [a body organ that stores urine] to drain urine) drain tube for Resident 8; 5. Appropriate hand hygiene between task while feeding residents was not followed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain equipment and environment in safe operating and sanitary condition when; 1. Unsteady bed side commode (a portable toilet, chair like structure to accommodate different user heights) with missing floor grip pads and broken chest of drawers in room for Resident 40; 2. Penetrating holes in room [ROOM NUMBER] and bathroom [ROOM NUMBER]; 3. Red to dark brown color metal plumbing pipes and missing on and off button for light switch in bathroom [ROOM NUMBER]. Above failures had the potential to adversely affect the health and safety of residents in facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure to follow their policy and procedure (P&P) for physician orders for life-sustaining treatment (POLST: a document that specifies the medical treatments the resident wants to receive during serious illness) for two of five sampled residents (Resident 3 and 8). These failures could lead to the delivery of unnecessary or inappropriate medical services against sampled resident's goals and wishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure free from unnecessary psychotropic medication (medications capable of affecting the minds, emotions, and behaviors) for one of four sampled resident (Resident 56) when: There was no documented evidence of non-pharmacological (treatments and strategies that mange health conditions without using medications) approaches attempted before administered psychotropic medication quetiapine (used to treat mental health condition); 2. There was no documented evidence for episodes of appropriate behavior monitored for quetiapine; 3. There was no documented evidence for side effects monitored for quetiapine. These above failures had the potential to place sampled resident at risk to receive unnecessary psychotropic medication.

Inspectors wroteBased on interview, and record review, the facility failed to accurately code the minimum date set (MDS: an assessment tool) assessment for one of three sample resident (Resident 3) when Resident 3's MDS assessment did not reflect status of the resident. This failure had the potential to affect inappropriate care and interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to implement comprehensive person-centered care plan for two of 14 sampled residents (Resident 4 and 29) when:Bilateral (both) heel boots were not applies while in bed for Resident 4;Floor mat (padded mat to reduce the risk of serious injury from fall) was not placed while Resident 29 was in bed. Above these failures had potentially affect Resident 4 and 29 's quality of care for prevention of pressure ulcer and injury in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to provide a restorative nurse assistant (RNA, a nursing program to increase and/or to prevent decrease in range of motion [ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point] exercise) program for one of 14 sample resident (Resident 4 ). Above this failure had the potential to result in further decline of ROM for sample Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of 18 sampled resident (Resident 5) was appropriately treated for a urinary tract infection (UTI, an infection of the bladder [body organ that collects urine] which causes burning while urinating, abdominal pain and blood in the urine) with an appropriate medication as ordered by the physician. This failure had the potential for further progress of UTI and affect Resident 5's overall health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving dialysis (medical treatment that filters blood to remove waste and excessive fluids from body to sustain life) treatment received care consistent with professional standards for two of three sampled residents (Resident 3 and 35) when:1. Inadequate communication from dialysis center (a place which provides dialysis treatment) to nursing facility for Resident 3; 2. Order for milk of magnesia (MOM: medication used to treat constipation [problem with passing stool]) for Resident 3 with dialysis status;3. Antibiotic (medication used to treat infection) order was not discontinued as ordered for Resident 3;4. No documented evidence for side effects (S/E, unwanted or unexpected effects that occur when taking medication) monitoring for use of antibiotic medications x2 for Resident 3;5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled substances (that can be easily abused and are under strict government control) when controlled medications were signed out of the controlled drug record (CDR, an accountability sheet of controlled medications) but not documented on the medication administration record (MAR) to show they were administered for 2 out of 4 residents (Residents 54 and 55). This resulted in facility not having accurate accountability and the potential for abuse/loss of controlled medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to conserve nutritional food value and palatability for one of 42 sampled resident (Resident 47), when:1. Resident 47 stated vegetables were soft, mushy and overcooked;2. A test tray for cooked vegetable was soft. This failure had the potential to compromise nutritional quality and palatability of meals for sampled resident 47.

Inspectors wroteBased on observation, interview and record review, the following multi-resident rooms were less than 80 square feet per resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of bed or side rails (adjustable rigid bars attached to the side of a bed) for five (Residents 26, 145, 194, 17, and 4) of five sampled residents (residents who used bed or side rails) when: 1. There was no documentation that indicated the facility followed the manufacturers' recommendations and specifications for installation and maintenance of the facility's beds and side rails for five of five sampled residents (Residents 26, 145, 194, 17, and 4); 2. There was no documentation that indicated alternatives were offered and/or attempted prior to the use of bed or side rails for three of five sampled residents (Residents 194, 17, and 4); 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain hygiene in the kitchen and to ensure food was stored in accordance with professional standards for food safety when: 1. Past use-by date food, rotten bananas, and dented cans were found in the freezer and on the shelves in the kitchen; 2. [NAME] K's (CK K) and dietary aid L's (DA L) hair were out of their hair nets; the maintenance director (MD) did not wash his hands when he entered the kitchen and opened the ice machine; the dietary director (DD) did not sanitize the thermometers before checking the food temperatures; and, 3. The screw in the ice storage bin was rusty with rusty water that dripped down onto the ice, and the ice machine did not have an air gap. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Licensed vocational nurse A (LVN A) picked up clean gauges and Silver Alginate (a sterile dressing for wounds with moderate to heavy exudate that helps prevent infection of wounds while providing optimum environment to facilitate healing) with her contaminated gloved hands for the treatment of Resident 9's wound; 2. Certified nursing assistant H (CNA H) did not sanitize her hands before serving a lunch tray to Resident 35; 3. LVN A went to Resident 17's room wearing the same gloves that she wore to give insulin to Resident 195, and then walked out of Resident 17's room with the same gloves on; 4. Restorative nurse assistant (RNA) did not perform hand hygiene in between residents during meal assistance; 5. [...]

Inspectors wroteBased on interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) for four of 13 sampled residents (Residents 34, 27, 17, and 7) when: 1. Resident 34's two different MDS assessments did not reflect the following: hospice care, facility acquired pressure injury (PI, damage to the skin caused by prolonged pressure), nutritional intervention, and the physician orders for life-sustaining treatment (POLST, a tool for end-of-life planning); 2. Resident 27's behavior of rejection of care was not reflected in the MDS assessment; 3. Resident 17's left sided weakness was not reflected in MDS assessment; and, 4. Resident 7's behavior of rejection of care was not reflected in MDS assessment. These failures resulted in inaccurate MDS assessments, which had the potential to affect the residents' care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received the necessary care and services for six of 13 residents (1, 7, 9, 22, 27,145 ) when: 1. Licensed vocational nurse A (LVN A), who worked with Resident 1 for a year, did not know Resident 1 had a pacemaker (a small battery-operated device that helps the heart beat in a regular rhythm); the facility did not have information on Resident 1's cardiologist and pacemaker, and did not schedule for Resident 1's pacemaker to be checked; 2. Resident 7 refused vitamin D3 4000 international unit (IU), cyanocobalamin (a manufactured version of vitamin B12) 1000 micrograms (ug, a metric unit of mass), and levothyroxine (used to treat an underactive thyroid gland which is a gland located beneath the voice box) 75 ug multiple times, and her refusals were not reported to the physician; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily staffing information posted was the current date. This failure had the potential to result in nurse staffing misinformation to residents, families, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure drug regimen review were done and acted on for three out of five residents (Resident 11, 15, and 31) when 1. Interim Medication Regimen Review (iMRR, a medication regimen review done when a resident had significant changes prior to the monthly drug regimen review) was not done for Resident 11 after multiple episodes of falls; 2. Consultant Pharmacist (CP) failed to identify and report irregularities related to a lack of monitoring of the blood pressures (BP, the pressure of blood on the walls of the arteries as the heart pumps blood) and heart rates of Resident 11 and Resident 15; and, 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's needs were accommodated for one of five sampled residents (Resident 17) when Resident 17's urinal (a container used to collect urine) was not within reach to use. This failure resulted in Resident 17 to not be able to reach his urinal.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy for two of three residents (Resident 19 and 146) when Resident 19 had an allegation of verbal abuse, and Resident 146 had allegation of financial abuse, but the allegations were not reported to the Adult Protective Services (APS). This failure left APS unaware of these allegations of abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to obtain a hospice admission order for one of two sampled residents (Resident 41) when Resident 41's admission orders had no indication of a hospice order. This failure had the potential to affect Resident 41's well being and care.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit the Minimum Data Set (MDS, an assessment tool) discharge assessment in a timely manner for one of three residents (Resident 12). This failure resulted in Resident 12's discharge assessment not being transmitted and received by the Center for Medicare and Medicaid System (CMS) within the time requirement.

Inspectors wroteBased on interview and record review, the facility failed to ensure a pre-admission screening and resident review (PASARR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurately completed for two of 13 sampled residents (Residents 27 and 21). These failures had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability, or related conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2, a colorless, odorless gas) use was provided for one of two sampled residents (Resident 15) when Resident 15's physician order for oxygen administration was not followed. This failure had the potential to result in complications related to improper treatment while receiving O2 therapy.

Inspectors wroteBased on interview, and document review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis on weekends based on, Census and Direct Care Service Hours Per Patient Day (DHPPD, a form containing daily staffing information). This failure had the potential to affect resident's care, health, and psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hazardous medications (medications that known to cause harm) were handled correctly and the safe and effective use of medications for two out of five (Resident 145 and 10) sampled residents when: 1. Two out of two licensed nurses were not knowledgeable on handling hazardous medications. This failure had the potential of harmful exposure for the staff through skin absorption. 2. Resident 145 received ferrous sulfate (iron, for prevention/treatment of iron deficiency anemia) tablet and magnesium oxide (medication used to relieve heartburn) tablet at the same time every day, when the co-administration could lead to decreased absorption of iron. This failure had the potential for the resident to not receive the amount of prescribed iron supplement as needed. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two out of five residents (Resident 11 and Resident 15) were free from unnecessary medications when: 1. An order for Carvedilol (a medication to treat high blood pressure and heart failure) did not include hold parameters (a fixed limit on when a medication should be given or held) relevant to blood pressure (bp, the pressure of blood on the walls of the blood vessels as the heart pumps blood) and heart rate for Resident 15. 2. An order for gabapentin (a medication to treat seizures) had an incorrect indication for Resident 11. 3. An order for amiodarone (a medication used to treat life-threatening heart rhythm problems) did not include heart rate monitoring for Resident 11. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 11) was free from unnecessary psychotropic medications (medications that cause changes in mood, feelings, or behavior) when: 1. Evaluation or Gradual Dose Reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose) of psychotropic medications was not considered after multiple falls. 2. There was no baseline Abnormal Involuntary Movement Scale (AIMS, a rating scale designed to measure involuntary movements which are side effects of long-term treatment of antipsychotic medications) for the use of aripiprazole (a medication used to treat mental/mood disorders). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had an 11.11% medication error rate when three medication errors out of 27 opportunities were observed during a medication pass for two out of five sampled residents (Residents 145 and 38) when: 1. Carvedilol (a medication to treat high blood pressure) tablet was not administered with food for Resident 145. Magnesium oxide (a medication used to treat heartburn) tablet and ferrous sulfate (an iron supplement) tablet were given at the same time for Resident 145. 2. Metformin (a medication used to treat high blood sugar) tablet was not administered with food for Resident 38. These deficient practices resulted in medications not given in accordance to manufacturer's specifications, which may result in unsafe and/or less than optimal therapeutic effect of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. An opened multi-dose insulin (a medication used to control high blood sugar) vial and an insulin pre-filled pen were found without labelling for their open dates. 2. An expired insulin pen and four expired over-the-counter medications were found. These failures had the potential for residents to receive medications with reduced efficacy.

Inspectors wroteBased on interview, and record review, the facility failed to maintain accurate and systematically organized documentation in accordance with accepted professional standards and practices for one of five sampled residents (Resident 41) when Resident 41's pronouncement of death was not properly documented. This failure resulted to an inaccurate documentation of Resident 41's death.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six residents (Residents 10 and 35) were offered and/or received pneumococcal (common bacteria that can affect different parts of the body) vaccinations. This failure increased the potential for residents to have inadequate immunity to pneumococcal infections (also known as pneumonia, an infection of one or both lungs).

Inspectors wroteBased on observation and interview, the following multi-resident rooms provided less than 80 square feet per resident, which had the potential to compromise the residents' care.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse reporting policy for one of four sampled residents (Resident 1). This failure resulted in an incident of abuse not being investigated and had the potential to compromise the safety of the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow up on the physician's order for one of three sampled residents (Resident 1) when they did not complete the referral for a urology (a part of health care that deals with diseases of the urinary tract) appointment. This failure had the potential to result in the delayed provision of Resident 1's urology needs and may result in worsening urology problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain room temperatures in accordance with their policy for one of nine sampled residents (Resident 1). This failure had the potential to compromise the resident's comfort, health, and overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to the accepted standards of clinical practice for two of 12 sampled residents (Residents 15 and 17) when: 1. Resident 15 did not have arm sleeves to protect his skin on the arms as ordered; 2. Resident 17's Advair HFA (an inhaler type of prescription medicine used to treat asthma) was not administered per the manufacturer's specifications. These failures had the potential to affect the residents' health condition and care.

Inspectors wrote2. Review of Resident 15's care plans indicated the resident was at high risk for falls related to history of falls, confusion, gait, and balance problems. Review of Resident 15's clinical records indicated the resident had fall incidents on 1/18/21, 3/3/21, 10/12/21, 1/2/22, 1/24/22, 2/6/22, and 2/18/22. Review of Resident 15's IDT Fall Review, dated 1/19/21, indicated the IDT reviewed the resident's 1/18/21 fall incident and the IDT did not recommend any new interventions or revise the current interventions to prevent falls. Review of Resident 15's IDT fall review, dated 1/26/22, indicated the IDT reviewed the resident's 1/24/22 fall incident and one of the recommendations was to take the resident to assess for bathroom privileges after lunch. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff assessed one of 12 sampled residents (Resident 7) for removal of an indwelling catheter (a tube inserted into the bladder to drain urine). This failure had the potential for the resident to have an unnecessary indwelling catheter with increased risk of catheter related complications i.e., infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure an attending physician visited and evaluated one of 12 sampled residents (Resident 8) in a timely manner. This failure had the potential to delay identifying the resident's medical needs and providing necessary care and treatment appropriately.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring of psychotropic medications for two of 12 sampled residents (Residents 5 and 15) when the side effects of Ambien (medication used to treat insomnia, a sleep disorder) were not monitored for Resident 5 and the Abnormal Involuntary Movement Scale (AIMS, test to monitor movement disorders in a person taking an antipsychotic medication) assessment was not completed for Resident 15. These failures had the potential to result in unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 12 sampled residents (Residents 6 and 11) had gradual dose reduction (GDR) attempts for their psychotropic medications (drugs that affects brain activities associated with mental processes and behavior). This failure resulted in the residents not having the opportunity to be free from the unnecessary psychotropic medications.

Inspectors wroteBased interview and record review, the facility failed to ensure rooms [ROOM NUMBER] had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive in the facility.