Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cathedral Health Care Center during CMS and state inspections, most recent first.
Missing Care Plans for Routine Medication Use: The facility failed to develop and implement comprehensive person-centered care plans for several residents receiving routine anticonvulsant, diuretic, and anticoagulant medications. Records showed that residents with severely impaired cognition were taking gabapentin, Lasix, and Xarelto as ordered, but their clinical records lacked corresponding care plans, and the DON/Administrator could not provide them when asked.
The facility failed to ensure proper infection control practices, as observed in several instances involving medication administration and resident care. An RN administered medication without hand hygiene and gloves, while another RN inadequately washed hands and did not use gloves for an injection. An LPN and a CNA also did not adhere to proper hand hygiene protocols, washing hands for less than the required 20 seconds. The facility's hand hygiene policy was not followed.
A resident with severe cognitive impairment experienced a fall and had an x-ray ordered for a finger injury, but the facility failed to notify the physician and resident representative of these events. The Director of Nursing and Administrator acknowledged the oversight, noting that while it was not policy to notify the physician after every fall, it was best practice to do so. The facility's notification policy requires prompt communication of condition changes.
The facility failed to ensure accurate MDS Assessments for residents, leading to discrepancies in medical records. A resident's TBI was not marked, another's bed rail was incorrectly noted as a restraint, and insulin administration was omitted for a third resident. The MDS Coordinator acknowledged these errors, and the facility lacked a specific policy for MDS completion.
A facility failed to follow physician's orders for a diabetic resident with severe cognitive impairment. The resident's blood sugar was recorded at 48, and instead of following the order to administer orange juice or soda, the RN provided a chocolate Ensure and an oatmeal cream pie. The blood sugar was rechecked at 68, but no further action was taken as required. The DON acknowledged the oversight, and the resident's MAR lacked documentation of necessary checks for low blood sugar.
The facility failed to conduct thorough fall risk assessments and update care plans for two residents with a history of falls. One resident's care plan was not updated after a fall, and another resident's fall risk evaluations were inaccurate, with delayed follow-up actions. The facility's policies on fall risk assessments and documentation were not adhered to, leading to deficiencies in managing resident falls.
A facility failed to document side effects of antipsychotic medication for a resident with paranoid schizophrenia. Despite orders to monitor side effects every shift, staff marked 'yes' for side effects without providing progress notes. Interviews revealed a misunderstanding among staff about documentation requirements, leading to incomplete records.
A resident with diabetes and severe cognitive impairment was administered the wrong type of insulin due to a medication error at the facility. The resident was prescribed NovoLOG Mix 70/30 FlexPen insulin but received Novolin R instead. The error was identified in a nurse's note, and the physician was notified. The Director of Nursing was informed, revealing a misunderstanding about the insulin types. The facility's medication administration policy, which requires verification of the correct medication and labeling of insulin pens, was not followed.
A resident with severe cognitive impairment and a colostomy had their colostomy bag inappropriately secured with duct tape for hospital transport, as the facility lacked proper securing methods. Despite the care plan's instructions, the facility used duct tape after medical adhesives failed, which was confirmed by the Facility Administrator. The resident was often found disrobed and without a colostomy bag, indicating a failure to adhere to professional standards of care.
Missing Care Plans for Routine Medication Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for 3 of 5 residents reviewed for unnecessary medications. Resident 2 had diagnoses including paranoid schizophrenia, bipolar disorder, and Parkinson's disease, and the most recent quarterly MDS indicated severely impaired cognition and receipt of an antipsychotic medication. Current physician orders showed gabapentin 400 mg three times daily for pain and Lasix 40 mg twice daily for edema, but the clinical record lacked a care plan for both the anticonvulsant and diuretic medications, even though the July 2025 MAR showed both were being administered routinely. Resident 7 had diagnoses including dementia with behaviors, stroke, diabetes mellitus type II, and heart failure, and the quarterly MDS indicated severely impaired cognition and receipt of an anticoagulant medication. The physician ordered Xarelto 10 mg daily for personal history of stroke, and the July 2025 MAR showed the medication was being given routinely, but the clinical record lacked a care plan for anticoagulant use. Resident 59 had diagnoses including bipolar disorder, dementia with psychotic disturbances, and chronic cystitis, and the quarterly MDS indicated severely impaired cognition and receipt of a diuretic medication. The physician ordered Lasix 20 mg daily for chronic cystitis, the MAR showed routine administration, and the clinical record lacked a care plan for diuretic use. The Administrator stated the residents were currently on those medications but could not provide a care plan for them and was unsure why they were missed.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment to prevent the transmission of infections, as observed in several instances involving medication administration and resident care. A Registered Nurse (RN) was seen administering medication to a resident without performing hand hygiene, handling medication with bare hands, and failing to use gloves during insulin administration. Another RN was observed washing hands inadequately and not using gloves while administering an injection. The Director of Nursing confirmed that medications should not be touched with bare hands, gloves should be worn during insulin administration, and handwashing should involve at least 20 seconds of lathering. Additionally, a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA) were observed not adhering to proper hand hygiene protocols. The LPN washed hands with an insufficient lather time before and after wound care, while the CNA washed hands for only five seconds after assisting a resident with a transfer. The facility's hand hygiene policy, dated January 2019, requires a minimum of 20 seconds of hand lathering to prevent infection spread, which was not followed in these instances.
Failure to Notify Physician and Representative of Resident's Condition Changes
Penalty
Summary
The facility failed to notify the physician and resident representative of a change in condition for a resident who experienced a fall and had an x-ray ordered. The resident, who had severe cognitive impairment and required supervision for mobility, fell on a specific date with no apparent injury, but there was no record of notification to the physician or representative. Additionally, the resident had an x-ray ordered for a swollen and crooked finger, but the representative was not informed of the x-ray order or its results, which indicated no fractures. Interviews and record reviews revealed that the resident's representative had not been contacted about any falls, injuries, or x-rays in several months. The Director of Nursing acknowledged that the nurse on duty should have notified the physician and family following the fall and x-ray, as per the facility's expectations. The Administrator noted that while it was not policy to notify the physician after every fall, it was considered best practice to do so. The facility's current notification policy mandates prompt notification of changes in a resident's condition to the physician and representative.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) Assessments for several residents, leading to discrepancies in their medical records. For Resident 5, the MDS Assessment did not accurately reflect the active diagnosis of Traumatic Brain Injury (TBI), despite the resident's clinical record indicating such a diagnosis. Additionally, Resident 27's MDS Assessment incorrectly marked the use of a bed rail as a restraint, which was not the case according to the MDS Coordinator. These inaccuracies were confirmed during interviews with the MDS Coordinator, who acknowledged the errors in the assessments. Furthermore, Resident 8's MDS Assessment failed to document the administration of insulin and injections, despite physician orders and the Medication Administration Review (MAR) indicating that insulin was administered during the assessment period. The MDS Coordinator admitted that the assessment was coded in error. The facility did not have a specific policy for completing MDS Assessments, relying instead on the Resident Assessment Instrument (RAI) manual.
Failure to Follow Physician's Orders for Diabetic Resident
Penalty
Summary
The facility failed to ensure comprehensive assessments were completed for a resident with diabetes, specifically after a low blood sugar reading. Resident 8, who has severe cognitive impairment and requires supervision for mobility, had a physician's order for blood sugar checks four times a day. The order also specified actions to take if the blood sugar was 70 or below, including administering orange juice or soda and rechecking the blood sugar after 15 minutes. On August 16, 2024, the resident's blood sugar was recorded at 48, and the RN on duty provided a chocolate Ensure and an oatmeal cream pie instead of following the specified order. The blood sugar was rechecked and recorded at 68, but no further action was taken as required by the physician's order. The Director of Nursing, who was on duty at the time, acknowledged that the physician's order was not followed after the blood sugar reading of 68. The resident's Medication Administration Record for August 2024 lacked documentation of an as-needed blood sugar check for readings below 70. The facility's staff nurse job description, which serves as a policy, requires accurate documentation and execution of physician's orders, which was not adhered to in this instance. This oversight in following the physician's orders and documenting the necessary actions led to the deficiency noted in the report.
Deficiencies in Fall Risk Assessments and Care Plan Updates
Penalty
Summary
The facility failed to ensure comprehensive assessments were completed appropriately for two residents reviewed for accidents. Resident 20, who has a history of schizoaffective disorder, bipolar type, type II diabetes mellitus, repeated falls, and other conditions, was observed propelling herself in a wheelchair and later standing up without using her walker. Her care plan was not updated after a fall on 5/23/24, and a fall risk assessment on 7/5/24 incorrectly indicated no falls in the previous three months, despite a fall occurring on 5/23/24. Interviews with the Administrator and Social Services confirmed that the care plan should have been updated after each fall, but it was not done for the fall on 5/23/24. Resident 8, who has severe cognitive impairment and issues with gait and mobility, experienced four falls between December 2023 and September 2024. Fall risk evaluations on 2/4/24 and 8/25/24 incorrectly indicated no falls in the past three months, and blood pressure checks from lying to standing were not conducted as required. A 72-hour follow-up for a fall on 8/25/24 was not initiated until 8/29/24, which was already 72 hours post-fall. The Director of Nursing acknowledged that the fall risk evaluations were not completed accurately and that staff needed further training. The facility's policies, provided by the Administrator, indicated that fall risk assessments should include evaluations of vital signs and medical conditions that may predispose residents to falls. However, these assessments were not conducted thoroughly, and the necessary documentation and follow-up actions were not completed in a timely manner. The lack of accurate fall risk assessments and timely updates to care plans contributed to the deficiencies identified in the facility's handling of resident falls.
Failure to Document Antipsychotic Side Effects
Penalty
Summary
The facility failed to adequately monitor and document side effects related to the use of antipsychotic medication for a resident diagnosed with paranoid schizophrenia. The resident was prescribed clozapine, an antipsychotic medication, with orders to monitor for side effects every shift. However, the clinical record review revealed numerous instances where nursing staff marked 'yes' for the presence of side effects without providing corresponding progress notes detailing the specific side effects observed. This lack of documentation occurred over several months, indicating a systemic issue in the monitoring process. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed a misunderstanding among staff regarding the documentation process. The DON indicated that there might be a key for staff to use when marking side effects, while the LPN believed that marking 'yes' simply indicated that the resident was monitored for side effects, not necessarily that side effects were present. This miscommunication led to incomplete records, as the staff did not document specific side effects in progress notes, contrary to the facility's policy and job description requirements.
Significant Medication Error: Incorrect Insulin Administered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving the administration of incorrect insulin. A resident with a diagnosis of diabetes and severe cognitive impairment was prescribed NovoLOG Mix 70/30 FlexPen insulin, with specific orders to inject 20 units once daily and 50 units once daily. However, the resident was mistakenly administered Novolin R, a short-acting insulin, instead of the prescribed Novolog, which is a mixture of intermediate and rapid-acting insulin. This error was documented in a nurse's note, which indicated that the resident received the incorrect insulin for their morning dose, and the physician was notified to monitor the resident. The Director of Nursing (DON) was informed of the error by the Unit Manager, who reported that an agency nurse had administered the wrong insulin. The DON noted a misunderstanding, assuming that Novolog and Novolin were the same, despite their differences in action. The facility's policy on administering medications, which requires verification of the right resident, medication, dosage, time, and method before administration, was not adhered to in this instance. The policy also mandates that insulin pens be clearly labeled with the resident's name and verified before use, which was not followed, leading to the medication error.
Inappropriate Colostomy Care with Duct Tape
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident, identified as Resident D, who required such services. Resident D had a colostomy and was diagnosed with severe cognitive impairment and schizoaffective disorder. The resident's care plan included specific instructions for colostomy care, such as changing the bag after each bowel episode or when full, using Skin-Prep barrier wipes, and monitoring for unusual behaviors like removing the ostomy bag. Despite these instructions, the facility did not adhere to professional standards when Resident D's colostomy bag was secured with duct tape for transport to a hospital. On a specific date, Resident D was observed in her room without clothing, lying on a blanket with visible brown substance, indicating fecal matter. The room had a strong odor of bowel movement, and the resident's stoma was uncovered. Staff assisted Resident D in cleaning up and dressing, and a new colostomy bag was applied. Interviews with staff revealed that Resident D frequently removed her colostomy bag, and duct tape was inappropriately used to secure the bag during transport to the hospital, as requested by the ambulance service. The facility lacked appropriate means, such as an abdominal binder, to secure the colostomy bag properly. The use of duct tape was confirmed by the Facility Administrator, who stated that medical-grade adhesives were ineffective, and the facility did not have alternative securing methods. The U.S. Department of Health and Human Services and the Food and Drug Administration guidelines were referenced, indicating that duct tape is not intended for medical purposes. The facility's policy on colostomy care, dated 2005, was reviewed, which included guidelines to prevent skin exposure to fecal matter and the use of adhesives if indicated. This deficiency was related to a complaint identified as IN00440005.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jasper
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Serenity Spring Senior Living At Northwood | 1.2 mi | ★★★★★ | 2 | 0 |
| Timbers Of Jasper The | 1.5 mi | ★★★★★ | 3 | 0 |
| St Charles Health Campus | 1.6 mi | ★★★★★ | 0 | 0 |
| Brookside Village Inc | 1.7 mi | ★★★★★ | 4 | 0 |
| Waters Of Huntingburg, The | 5.8 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.