St. Catherine Center

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status for one (Resident #50) of four residents reviewed for change of condition. The facility failed to recognize a change in condition in Resident #50 on 3/13/2026 after she was reported to the CNA to be experiencing stroke like symptoms and Resident #50 was not transported to the hospital until 3/14/2026. This deficient practice could place residents at risk for injury and harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 6 residents (Resident #65 and Resident #137) reviewed for resident rights. The facility failed to ensure CNA B knocked on Resident #137's door before entering the resident's room. The facility failed to ensure CNA E knocked on Resident #65's door before entering the resident's room. The facility failed to ensure CNA F knocked on Resident #65's door before entering the resident's room. These failures could place residents at risk of feeling like their privacy was invaded or cause psychosocial harm and emotional distress.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed. The facility failed to ensure Dietary Staff performed good hand hygiene within the context of food handling and sanitation. This failure could place residents at risk of cross contamination and the potential transmission of infectious organisms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #119) of seven residents reviewed for ADL care. The facility failed on 04/28/2026 to ensure they cleaned Resident #119's motorized wheelchair for an indeterminant amount of time. This failure could place residents at risk of infection, and loss of dignity.

Inspectors wroteThe facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration, was provided with such care, consistent with professional standards of practice for 1 (Resident #1) of 5 residents reviewed. The facility failed to apply Resident #1's APAP (Automatic Positive Airway Pressure- a type of non-invasive mechanical ventilator) machine at HS (Hour of Sleep) for 15 days out of 29 for the month of October. This failure could place residents who require respiratory care at risk of distress including respiratory failure leading to hospitalizations or even death.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main facility kitchen and 3 of 3 satellite kitchens (second floor, third floor, fourth floor). The facility failed to ensure the cornmeal, sugar, breadcrumbs, salt, and parboiled rice packages were re-sealed in the dry pantry. The facility failed to ensure the walk-in cooler for produce in the main kitchen did not have food packages stored on the floor. The facility failed to ensure the walk-in freezer in the main kitchen did not have food packages stored on the floor. The facility failed to ensure the single door reach in cooler in the main kitchen was clean and free of food debris. The facility failed to ensure the small microwave in the main kitchen was clean. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure accurate assessments were completed for 2 of 30 residents (Residents #6 and #87) reviewed for accuracy of assessments. The facility failed to ensure Residents #6 and #87's MDS assessment was accurately coded for Preadmission Screening and Resident Review (PASRR). This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be informed of, and participate in, his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for one of (Resident #1) of three residents review for medication changes. The facility failed to obtain written consent from Resident #1's Representative (RP) before administering her Seroquel (for psychosis). This failure could place residents at risk of not having their preferred responsible party represent them in medical and care decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 5(Residents #3, #71, #83, #84 and #94) of 8 residents reviewed for infection control in that: MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #3, #71, #84 and #94. LVN B failed to disinfect the stethoscope prior to and after use during g-tube (feeding tube) medication administration for Residents #84. These failures could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 2 (Residents #17 and #120) of 9 residents reviewed for Residents Rights. The facility failed to ensure MA C logged out of her computer and protected Resident#17 and #120's's MAR's. This failure could place residents at risk of being vulnerable to exploitation of their insurance benefits resulting in fraud and possible embarrassment resulting in distress and loss of dignity and causing a decrease in their psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning for one (Resident #111) of six residents reviewed for PASRR assessments. The facility failed to provide a specialized Customized Wheelchair to Resident #111, after her 11/22/23 IDT meeting, when a request for a CWC was made but the NFSS form was not submitted until 01/16/24. And as of 01/25/24 Resident #111 had not received her Customized wheelchair. SW E failed to notify MDS Coordinator Director H about Resident #111's need for a Specialized Customized Wheelchair. [...]

Inspectors wroteBased on interview and record review the facility failed to coordinate assessment with the preadmission screening and resident review (PASSR) program to the maximum extent practicable to avoid duplicative testing and effort which included incorporating the recommendation from the PASSR level II determination into the resident assessment, care planning and transition of care for one (Resident # 1) of one resident reviewed. The facility failed to provide specialized service to Resident # 1 due to the facility not submitting the Nursing Facility Specialized Services (NFSS) request form in the Simple LTC portal. This failure could place residents at risk of not receiving necessary care of specialized service which could diminish the residents' quality of life and highest level of functioning.