St. Catherine Healthcare

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the safety of the residents when one of two volunteer staff (the Activity Volunteer) with a prior history of conviction was recruited to work with the residents. * The Activity Volunteer was a current sex offender registrant who was volunteering in the facility. This failure had the potential to put the residents at risk of harm or negative outcomes.

Inspectors wroteBased on interview, medical record review, facility document review and facility P&P review, the facility failed to implement their antibiotic stewardship program to show timely physician notification for two final sampled residents (Residents 17 and 49) and three nonsampled residents (Residents 16, 47, and 93) who received antibiotics for infections that did not meet McGeer's criteria. * The facility failed to ensure Resident 47's symptoms met the criteria for a UTI, notify the physician the infection did not meet the criteria, and reassess the need for continued antibiotic therapy. * Resident 16's physician was notified the UTI infection did not meet the criteria, however there was no indication as to when the physician was notified. Additionally, the form was completed by the IP who was out of the facility at the time and returned in March 2026. [...]

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure one of 19 final sampled residents (Resident 6) and one nonsampled resident (Resident 41) were assessed to self-administer medications. * Resident 6's bedside table was observed with a bottle of Mylanta (antacid and anti-gas medication) on top of bedside table. There was no physician's order for the Mylanta medication and no self-administration assessment for Resident 6. * Resident 41's bedside table was observed with a Biofreeze Cool the Pain (topical analgesic) medication on top of bedside table. There was no physician's order for the Biofreeze Cool the Pain and no self-administration assessment for Resident 41. These failures had the potential for the residents to administer the medications inaccurately and negatively impact the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Advance Directive and POLST were complete for one of 19 final sampled residents (Resident 32). * Resident 32's Advanced Directive did not show who the resident selected as his health care agent. In addition, the facility failed to ensure the POLST completed with Family Member 1 matched the resident's wishes for life sustaining treatment as detailed in Resident 32's Advanced Directive. This failure had the potential for the resident's end of life wishes not being followed.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure two of seven final sampled residents (Residents 7 and 8) reviewed for unnecessary medications were free from unnecessary psychotropic drugs. * The facility failed to document the nonpharmacological interventions to be attempted when Resident 7 had an episodes of angry outbursts. * The facility failed to ensure the episodes of anxiety were monitored for Resident 8. In addition, the facility failed to provide interventions to address Resident 8's behavior when the resident exhibited agitation and angry outbursts. These failures had the potential for adverse effects from the psychotropic medications and the potential for not providing the correct data to the prescriber to adjust the dosage of the psychotropic medications.

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current care needs and interventions for one of 19 final sampled residents (Resident 5). * The facility failed to revise Resident 5's care plan to address the interventions for the left arm AV fistula. This failure posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure two licensed nurses reviewed for competency had specific competencies and standard of practice skill sets needed to provide safe and efficient nursing care. * The facility failed to ensure LVN 3 was able to demonstrate competency in the calibration of a glucometer accucheck machine (a device used to measure the concentration of glucose in the blood). * The facility failed to ensure RN 2 was able to competently administer the correct intravenous medication dosage to Resident 101. These failures had the potential to put the residents at risks for the care not provided in a safe and competent manner.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the correct dosage of the medication was administered as per physician's order for one of 19 final sampled residents (Resident 101) observed for medication administration. * RN 2 failed to ensure the correct dosage of Resident 101's IV ertapenem (antibiotic) medication was administered per physician's order. This failure posed the risk for negative health outcomes for Resident 101.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary pharmacy services to ensure proper labeling of the medications for three nonsampled residents (Residents 41, 52, and 69). * The facility failed to ensure the medications for Residents 41, 52, and 69 were properly labeled with open date. This failure had the potential for the residents to have received expired medications and risk of undermining the efficacy of the stored medications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the facility's garbages and refuse was properly disposed for one of three garbage dumpsters. * One blue garbage dumpster was not fully closed. This failure had the potential to cause unsafe sanitary conditions and potential to harbor pests and rodents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record were complete and accurately documented for four of 19 final sampled residents (Residents 5, 32, 42, and 107). * The facility failed to ensure Resident 5's BP access site was accurately documented in the medical record. * Resident 32's Advanced Directive was missing a page and failed to show who he selected as his healthcare agent. * The facility failed to ensure the Narcotic and Hypnotic Record form was properly documented for Resident 42. * Resident 107's POLST showed the resident did not have an Advanced Healthcare Directive, however the resident did have one at her home. These failures have the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete.

Inspectors wroteBased on interview and facility document review, the facility failed to implement the facility's QAPI plan and the past Recertification Survey POC for F554 and F761. * The facility failed to show audits and/or monitoring tools were completed per the facility's POC for F554 and F761. This failure had the potential for ongoing non-compliance and complete data being reviewed by the QAPI committee.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed. * The facility records showed Resident 47 had a UTI, when the resident's symptoms did not meet criteria for a true infection. * The facility failed to ensure the Medication Cart A's fourth small drawer was free of medication spillage. In addition, the iron liquid bottle was observed with sticky spillage. * LVN 4 failed to perform hand hygiene and change gloves after touching Resident 87's surroundings, before checking the GT and administering the medications. These failures posed the risk for transmission of disease-causing microorganisms and infections to the residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to protect the residents' identifiable information.* The facility's survey results binder for public viewing included three confidential resident rosters. This failure resulted in confidential residents' information being accessible to the public.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for one of 19 final sampled residents (Resident 49). * The facility failed to ensure Resident 49's nasal cannula tubing was dated and labeled as per the facility's P&P. In addition, the facility failed to ensure the nasal cannula tubing was stored in a set-up bag when not in use for Resident 49. This failure had the potential for the residents not to receive the appropriate care and may negatively impact the resident's medical conditions.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive care plan to reflect the individual care needs for one of three sampled residents (Resident 1). * The facility failed to develop a care plan to address Resident 1's alleged abuse incident on 1/9/26. This failure had the potential risk of not providing the appropriate, consistent, and individualized care to Resident 1.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of seven final sampled residents (Resident 1) was informed of the indication for the use of medications affecting brain activities associated with mental processes and behavior. * The facility failed to ensure Resident 1's informed consent was obtained when the indication for the use of Ativan (lorazepam, a benzodiazepine class of medication used to treat anxiety) was changed in frequency in administration from every six hours to every eight hours. * The facility failed to ensure Resident 1's informed consent was obtained for the use of Depakote (an anticonvulsant medication for labile mood). These failures had the potential for Resident 1 not to be informed of the medications and potential side effects of the use of Ativan and Depakote medications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of seven sampled residents (Residents 1) was free from unnecessary psychotropic (medication affecting brain activities associated with mental processes and behavior) medications. * The facility failed to ensure Resident 1 was adequately monitored for the Depakote medication. This failure posed risk for Resident 1 to cause potential harm from adverse consequences and a significant decline in functioning.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of five sampled residents (Resident 5) reviewed for falls received the necessary care and services for the resident at risk for fall. * The facility failed to monitor and initiate a care plan when Resident 5 reported a fall on 9/1/25. This failure had the potential for the delay in providing the necessary care and services and posed a risk for Resident 5 to sustain serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P, the facility failed to ensure the protocols were followed for oxygen administration for four of four sampled residents (Residents 1, 2, 3, and 4). * Residents 2, 3, and 4 were administered with more than the liters per minute ordered by the physician. * Resident 1's MAR failed to show documentation of the administration of the oxygen PRN. These failures had the potential for adverse respiratory outcomes and resulted in inaccurate administration records for the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of ninesampled residents (Resident 2). * The facility failed to timely provide and administer Resident 2's medications as per the physician's orders on 11/26 and 11/27/24. * The facility failed to follow up and notify the physician regarding Resident 2 of not receiving his medications due to pending delivery status of the ordered medications. These failures had the potential to negatively affect the resident's health condition and well-being.

Inspectors wroteBased on observation, interview, medical record review, facility P&P review, the facility failed to ensure three of nine sampled residents (Residents 3, 4, and 5) remained free from accident hazards. * Resident 3's fall risk care plan showed the interventions including for the resident's bed to be in the lowest position and for the bilateral floor mats. However, the bed was not in the lowest position and the floor mat was folded up against the wall. * Resident 4's fall risk care plan addressing the resident's actual fall showed interventions including to maintain a clear pathway, free of obstacles, needs a safe environment: floor free from spills and/or clutter. However, the bedside table was placed on top of the floor mat next to the resident's bed. [...]

Inspectors wroteBased on interview, medical record review, and the facility's P&P review, the facility failed ensure the accuracy of the MAR for one of nine sampled residents (Resident 2). This failure had the potential for the resident's care needs not being met.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility failed to ensure the thawing process for meats was followed as per the facility's P&P. * The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions. * The facility failed to ensure the food preparation equipment were in good condition. * The facility failed to remove a bag of ham with freezer burns. * The facility failed to ensure a food preparation sink had an air gap for back flow prevention. These failures had the potential to pose the risk for exposure to food-borne illnesses in a medical vulnerable population of 86 that received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented as evidenced by: * The facility failed to implement their infection control surveillance program for January through August 2024. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobials. Residents who were not prescribed antimicrobials were not included in the facility's infection control surveillance program. * The facility failed to accurately track and monitor for the infections for February, May, and June 2024. * The facility failed to ensure the infection control practices were implemented on a resident with transmission-based precautions. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe for one of 18 final sampled residents (Resident 77) to self-administer medications. * Resident 77 was observed to have medications inside a medicine cup at the bedside. Resident 77 did not have an assessment, a physician's order, or a care plan problem addressing the self-administration of medications. This faiure had the potential for Resident 77 to administer medications inaccurately.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure recommendations from the Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) level II determination was followed up, as per the facility P&P and incorporated into the resident's plan of care for one of two final sampled resident (Resident 8) reviewed for PASARR. This failure had the potential for Resident 8 not receiving the adequate care that was recommended by PASARR level II determination and evaluation report assessed by an appropriate state-designated authority.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services were provided related to the use of a GT for one of 18 final sampled residents (Resident 65). * The facility failed to ensure Resident 65's GT was checked for placement prior to medication administration, flushed with at least 5 ml of water between each medication as per the facility's P&P, and flushed with 20 to 30 ml of water following medication administration as per the physician's order. This failure had the potential for GT blockage affecting the resident's health and well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services related to a PICC line for one of 18 final sampled residents (Resident 537). * The facility failed to obtain the measurement of the right upper arm circumference upon admission and dressing changes. In addition, the facility failed to develop a care plan problem to address the use of a PICC line catheter. These failures posed the risk for the resident to development complication such as catheter migration and dislodgement.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain and maintain the highest well-being for one of 18 final sampled residents (Resident 63). * The facility failed to monitor Resident 63's fluid restriction as per the physician's order. In addition, the facility failed to ensure Resident 63's dialysis access site was assessed prior and after dialysis treatments. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement alternative measures prior to the use of bed rails for two of 18 final sampled residents (Residents 63 and 537). This failure created the potential to put the residents at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 18 final sampled residents (Resident 7) was provided the medications as ordered by the physician. * The facility failed to ensure Resident 7 had a physician's order for nasal moisturizing spray. This failure had the potential of not meeting the resident's needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure for the safe storage of the medications and supplies. * The IV Cart was observed to contain the expired supplies along with other supplies without a manufacturing or expiration date. * An opened bottle of Gerilanta (a laxative medication) was observed in Medication Cart 2 with no open date. These failures had the potential to result in unsafe administration of the medications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed when fortified (additional nutrients added through foods such as butter and cream) diets were not followed for one nonsampled resident (Resident 19). This failure had the potential for Resident 19 to not receive the diet as planned which may lead to compromised nutritional status.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure dietary texture guidelines were followed as per the facility's P&P, for one nonsample resident (Resident 19) who was on a pureed diet. This failure had the potential to lead to choking or aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airway) for Resident 19.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the education was provided to the staff and family/visitor on safe food handling of outside food as per the facility's P&P. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program when the facility failed to conduct an assessment for the McGeer's criteria to determine the true infection. This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antimicrobials.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to properly obtain the informed consents (permission granted in the knowledge of the possible consequences) for the use of psychotropic medications (medications affecting brain activity) and treatments from the responsible party (person designated to make decisions on behalf of the residents) for one of 18 final sampled residents (Resident 23). This failure posed the risk for Resident 23 and their responsible parties to not be informed of their medications and the potential side effects.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain and maintain copies of the advance directive in the medical record for one of 18 final sampled residents (Resident 10). This failure had the potential for confusion or failure to provide care and life sustaining measures in accordance with the residents' treatment wishes.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to complete the post fall neuro-checks at the specific time frames as per the facility's 72 hours Neuro-check Monitoring process for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience medical complications which could go unnoticed post fall.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the accuracy of medication administration documented on the MAR for one of three sampled residents (Resident 1). This failure posed the risk of having error in medical care and delay in treatment.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the measuring buckets used for food portioning were air dried prior to storing. * The facility failed to ensure the kitchen utensils were clean, free of food particles, and not worn out. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections during a COVID-19 facility outbreak. * The facility failed to follow timely reporting of a COVID-19 outbreak to local and state health agencies. * The facility failed to follow the infection control practices in the clean linen area. These failures had the potential to delay response time and containment of a COVID-19 outbreak.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to accurately and timely identify and report CAI and HAI cases. This failure had the potential of not accurately identifying infections and timely notification to the health care provider resulted in inaccurate data being reviewed by the Infection Control Committee.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to properly obtain the informed consent (permission granted in the knowledge of the possible consequences) from the responsible party/POA (persons designated to make decisions on behalf of the residents) for one of 18 final sampled residents (Resident 22). * A verbal consent for medical treatment and influenza (a contagious respiratory illness caused by flu viruses spread mainly by coughing, sneezing, and close contact) vaccine administration was obtained from Resident 22 who was assessed by the physician as not able to make medical decisions. The facility failed to ensure the consent for medical treatment and influenza vaccination was obtained from Resident 22's responsible party. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to follow the physician's order for one of 18 final sampled residents (Resident 18). Resident 18 was administered guiafenesin instead of the dextrometorphan guiafenesin ordered by the physician. This failure had the potential for adverse outcomes to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for the GT feeding of one of 18 final sampled residents (Residents 21). * The facility failed to ensure Resident 21 received the accurate amount of enteral feeding as ordered by the physician. This failure had the potential for not meeting the resident's nutritional needs

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services to one nonsampled resident (Resident 36). * Resident 36 was administered oxygen without a physician's order. In addition, Resident 36's oxygen tubing touching the floor. These failures had the potential to put Resident 36 at risk for negative health outcomes and adverse effects of the improper care and administration of oxygen.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the appropriate pain management for one of 18 final sampled residents (Resident 280). * The facility failed to ensure Resident 280's pain was addressed when she reported a pain level of 7 (severe pain) on a pain scale of 0-10 (with 0=no pain and 10=worst pain). Resident 280 had reported severe pain with a pain level of 7 multiple times but was only provided a pain medication prescribed by the physician for moderate pain (pain level of 4-6). This failure had the potential to affect the resident's well-being and unnecessary pain.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the assessment for entrapment, alternative for the use of side rails and the care plan was completed for one of 18 final sampled residents (Resident 59). * Resident 59 was observed with bilateral side rails. The facility failed to ensure the entrapment assessment, physician's order, and care plan problem were initiated prior to its use. Failure to establish a comprehensive approach for the use of bed rails posed a potential risk for residents including entrapment and/or injury due to lack of proper installation and preventive maintenance, and not meeting resident needs by informing them of risk and benefits.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of 18 final sampled residents (Resident 59's) medical record was complete. * Resident 59's medical record did not include the physician's progress notes. This failure had the potential for the physician's plan of care for the resident to not be effectively communicated to the interdisciplinary team.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage and refuse were properly stored in one of three garbage dumpster. The lid of the one garbage dumpster was left partially open. This failure had the potential to harbor pests or rodents which carry diseases.