Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 St. Catherine Center during CMS and state inspections, most recent first.
A resident with a history of CVA, neuropathy, HTN, and GERD had a significant change in condition with facial drooping, slurred speech, drooling, and weakness that was reported by a family member and later observed by staff. Staff did not immediately notify the MD or resident representative, and the resident was not sent to the hospital until the next day. Interviews showed some staff attributed the symptoms to Parkinson's, while the physician stated stroke signs should prompt provider notification and the resident had an acute CVA.
Failure to Knock Before Entering Resident Rooms: Staff entered two residents' rooms without knocking, including a CNA and an LVN entering rooms unannounced during observations. Both residents had moderate cognitive impairment, and one resident stated staff sometimes knocked and sometimes did not, while the other said staff sometimes entered without knocking and she had not complained. Staff and the DON stated that knocking before entering was expected, even when doors were open, and the facility policy required associates to knock and request permission before entering residents' rooms.
Improper Food Handling and Hand Hygiene in Kitchen: A dietary aide was observed picking up a hamburger patty with bare hands during lunch service without gloves or utensils. Interviews with dietary staff and the DIR confirmed that staff were expected to wear gloves and wash hands when handling food, and the facility policy required food to be protected from cross-contamination and hands to be scrubbed using proper hand-washing techniques.
A resident with CAD, HTN, kidney failure, DM, legal blindness, morbid obesity, and a motorized wheelchair had a visibly soiled chair with debris and food residue on the footrest, arm rests, and seat area. The resident said staff did not normally clean the wheelchair or offer to clean it, and staff interviews showed CNA cleaning was expected on night shift, but there was no documentation showing when the task was completed. The DON, IP, and CNAs were unable to show when the resident’s wheelchair had last been cleaned.
A resident with significant physical and cognitive impairments did not receive prescribed APAP therapy for 15 days in a month, despite physician orders and care plan directives. Staff interviews and device data confirmed the therapy was not administered, and there was no documentation of refusals or reasons for missed treatments, contrary to facility policy.
The facility failed to maintain sanitary conditions in its main and satellite kitchens, with unsealed food packages, improper food storage, and unclean equipment observed. Dust accumulation on air vents above serving areas and staff not wearing required hairnets further contributed to the deficiencies. These issues were identified during observations and interviews, highlighting lapses in adherence to facility policies and procedures.
The facility failed to accurately assess two residents' MDS for PASRR, leading to incorrect coding. A resident with schizoaffective bipolar disorder and another with bipolar disorder were both marked incorrectly in their MDS assessments, despite positive PASRR screenings for mental illness. The MDS Coordinator misunderstood the relationship between active diagnoses and PASRR screening, resulting in these inaccuracies.
A facility failed to obtain written consent from a resident's representative before administering Seroquel, a psychotropic medication, despite the resident's severe cognitive impairment and potential for drug-related complications. The representative was not informed of the medication changes, and the facility's policy did not explicitly require consent, leading to a deficiency in ensuring residents were fully informed and involved in their care.
Failure to Report Stroke-Like Change in Condition
Penalty
Summary
The facility failed to immediately inform the resident, the resident's physician, and the resident representative when Resident #50 had a significant change in condition. Resident #50 was an older female with a history of unspecified sequelae of cerebral infarction, idiopathic peripheral autonomic neuropathy, hypertension, and GERD. Her quarterly MDS showed a BIMS score of 07, indicating severe impairment, and her care plan identified her as at risk for impaired communication related to change in environment. On 3/13/2026, the resident's family member reported seeing facial drooping, slurred speech, and drooling while visiting the resident and told a CNA that the resident looked like she was having a stroke. The family member stated she went to the nurses' station and was told the symptoms were due to Parkinson's, and she reported there was no staff follow-up with vital signs. The record showed the resident was not transported to the hospital until 3/14/2026, when a progress note documented right-sided weakness, right facial drooping, slurred speech, and inability to assist with transfers as usual. Interviews reflected conflicting staff observations, with some staff stating they did not notice changes and others stating the resident did not look right and had slurred speech and transfer difficulty. The nurse manager stated there was no verbal or written communication of stroke symptoms on 3/13/2026, and the DON stated the nursing staff sent the resident to the hospital the next day after the family raised concerns. The physician stated that once stroke signs and symptoms were recognized, a provider should be notified, and the resident had an acute CVA. The facility policy required the nurse to notify the health care provider when there was a significant change in the resident's physical, emotional, or mental condition.
Failure to Knock Before Entering Resident Rooms
Penalty
Summary
The facility failed to treat residents with respect and dignity by not ensuring staff knocked before entering resident rooms for 2 of 6 residents reviewed for resident rights, including Resident #65 and Resident #137. Resident #65 was a female admitted to the facility with diagnoses including cerebral infarction affecting the left non-dominant side and unsteadiness in the feet. Her quarterly MDS assessment dated 04/17/2026 showed a BIMS score of 12, indicating moderate cognitive impairment. Resident #137 was a female admitted to the facility with diagnoses including transient cerebral ischemic attack and limitation of activities due to disability. Her quarterly MDS assessment dated 04/17/2026 showed a BIMS score of 11, also indicating moderate cognitive impairment. During an observation and interview with Resident #65 in her room, CNA F entered without knocking. Resident #65 stated that sometimes staff knocked and sometimes they did not. During an observation and interview with Resident #137 in her room, LVN G entered without knocking, and Resident #137 stated there were times when staff did not knock before entering and that she had not made a complaint. Later, CNA B was observed entering Resident #137's room without knocking. CNA B stated she was supposed to knock before entering, said she was in a hurry and forgot, and acknowledged that not knocking would be a resident rights issue because the resident could be in the middle of receiving care. Interviews with staff and leadership showed that staff were expected to knock before entering resident rooms unless there was an emergency. LVN G stated that even if a door was open, staff still needed to knock and introduce themselves, and that failing to do so violated residents' rights. RN H, CNA C, CNA D, LVN A, and the DON all stated that staff should knock before entering rooms and that they monitored or reinforced this expectation through rounds, huddles, orientation, or education. Review of the facility policy titled 'Quality of Life - Dignity' dated 12/2021 stated that associates will knock and request permission before entering residents' rooms.
Improper Food Handling and Hand Hygiene in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one kitchen reviewed. During an observation on 04/28/2026 at 11:45 AM, a dietary aide was seen picking up a hamburger patty with her hands during lunch service. She was not wearing gloves and was not using utensils to remove the meat from the pan. During interviews, the dietary aide stated her duties included setting up trays, serving residents, and cleaning the dining area, and she acknowledged that picking up food with her hands was not normal practice. Another dietary aide stated staff should wear gloves while handling food and wash their hands before, during, and after handling food. The cook stated that staff handling food should wash and put gloves on immediately if they forget, and that it was not normal practice to handle food without gloves. The dietary director stated that no food should have been picked up with bare hands and confirmed that staff were expected to always wear gloves. The facility policy on Food Handling Guidelines stated that food should be protected against cross-contamination and that hands should be scrubbed using appropriate hand-washing techniques, including before putting on gloves.
Soiled Resident Wheelchair Not Cleaned
Penalty
Summary
The facility failed to ensure Resident #119’s motorized wheelchair was cleaned for an indeterminate period of time. Resident #119 was a [AGE]-year-old male with diagnoses including coronary artery disease, hypertension, kidney failure, diabetes mellitus, hyperlipidemia, legal blindness, and morbid obesity. His MDS reflected impairment of both lower extremities, use of a motorized wheelchair, and a BIMS score of 11. His care plan identified that he was at risk for infection due to wounds, at risk for pressure ulcers and/or impaired skin integrity, and needed assistance with daily ADL care. During observation, Resident #119 was sitting in a motorized wheelchair that was visibly soiled with debris on the footrest, arm rests, plastic above the wheels, and the visible portion of the seat cushion. He stated he was legally blind and that staff did not normally clean his wheelchair or offer to clean it. He also stated he had not asked staff for help cleaning it because he did not know they would do that for him. He reported that he had dropped a piece of meat on the chair the day before, and a golf ball-sized red/brown goo was observed at the bottom of the wheelchair near the footrest. Interviews with the IP, LVNs, CNAs, and the DON showed that the facility’s practice was for CNA staff, primarily on night shift, to clean resident wheelchairs on a weekly schedule, but there was no documentation showing when the task was completed. Staff stated they used spot checks and rounding to monitor cleanliness, and several staff members said they were unsure when Resident #119’s wheelchair had last been cleaned. The facility policy stated that direct care staff are responsible for cleaning single-resident equipment when visibly soiled and according to routine schedule where applicable.
Failure to Provide Prescribed Respiratory Care and Document Therapy Refusals
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral palsy, spastic quadriplegic cerebral palsy, muscle weakness, and dysphagia, who was dependent on staff for all activities of daily living, did not consistently receive prescribed respiratory care. The resident had a physician's order for an APAP (Automatic Positive Airway Pressure) machine to be applied at hour of sleep, as documented in the care plan and physician's orders. Despite this, internal device reports showed that the APAP machine was not used for 15 out of 29 days in October, with no documented refusals or explanations in the treatment records or progress notes for those days. Interviews with facility staff, including the unit supervisor, respiratory therapist, and DON, confirmed that the resident was supposed to use the APAP machine nightly and that nursing staff were responsible for applying the mask and turning on the device. Staff indicated that if the resident refused the therapy, it should have been documented, but there was no such documentation for the missed days. The responsible party for the resident was notified by the supply company about the lack of usage data and expressed concern, noting the resident's inability to apply the device independently due to limited mobility. The facility's policy required documentation of refusals and reasons for missed therapy, but this was not followed. The lack of APAP usage was confirmed by both internal device data and staff interviews, with no evidence that the resident refused the therapy or that staff made additional attempts to apply the device as required. The deficiency was identified through record review, interviews, and observation, demonstrating a failure to provide respiratory care and services consistent with professional standards of practice.
Sanitation and Food Safety Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain sanitary conditions in its main kitchen and three satellite kitchens, leading to potential risks of foodborne illness for residents. Observations revealed that packages of cornmeal, sugar, breadcrumbs, salt, and parboiled rice in the dry pantry were not re-sealed, and food packages were stored on the floor in both the walk-in cooler and freezer. Additionally, the single door reach-in cooler and a small microwave in the main kitchen were found to be unclean, with food debris and dried food splatters present. Interviews with the acting Dietary Manager (DM) indicated that another employee was responsible for pantry, cooler, and freezer maintenance, but was off duty at the time of the inspection. Further observations highlighted cleanliness issues in the satellite kitchens on the second, third, and fourth floors, where dust was found on air vent grates directly above serving steam tables. The Maintenance Director admitted to being unaware of the dust accumulation and acknowledged that the vents should be cleaned monthly to prevent contamination. The facility's Sanitation and Infection Prevention/Control policy assigns the Maintenance Department the responsibility for cleaning equipment, but the oversight in cleaning the air vents was noted as a lapse in adherence to this policy. Additionally, staff members were observed not adhering to the facility's dress guidelines for food service management. DA A in the fourth-floor satellite kitchen was seen handling food without a hairnet over his beard, citing a lack of supplies. Similarly, DS C was observed in the main kitchen without a hairnet, acknowledging the oversight upon seeing the surveyor. The Director of Nursing (DON) confirmed that hairnets should be worn at all times in the kitchen areas, covering both head and facial hair, and noted that this requirement had been recently discussed with staff.
Inaccurate MDS Assessments for PASRR in Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in the coding of their Minimum Data Set (MDS) assessments concerning the Preadmission Screening and Resident Review (PASRR). Resident #6, a female with schizoaffective bipolar disorder, anxiety, and major depressive disorder, was inaccurately coded in her MDS assessment. Despite her PASRR Level 1 screening indicating a positive result for mental illness, her MDS Section A1500 was marked as 'No' for serious mental illness, contradicting her active diagnoses and medication records. Similarly, Resident #87, a male with bipolar disorder, major depressive disorder, and anxiety disorder, was also inaccurately assessed. His PASRR Level 1 screening and evaluation confirmed a positive result for mental illness, yet his MDS Section A1500 was incorrectly coded as 'No' for serious mental illness. The MDS Coordinator admitted to misunderstanding the relationship between Section I Active Diagnoses and Section A PASRR screening, leading to these inaccuracies. This oversight could potentially risk residents not receiving appropriate care and services.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding medication changes. This deficiency was identified through interviews and record reviews, revealing that the facility did not obtain written consent from a resident's representative before administering Seroquel, a psychotropic medication. The resident, who had severe cognitive impairment and was receiving antipsychotic, antidepressant, and hypnotic medications, had a care plan indicating a potential for drug-related complications. Despite this, the consent forms for the medication changes were not signed by the resident's representative. During interviews, the resident's representative stated they were not notified nor gave consent for the medication, expressing a desire to be involved in the resident's care. The Director of Nursing acknowledged the expectation for consent to be signed by the resident or their representative before administering psychotropic medications, noting that the facility's policy did not explicitly require consent but included it as an attachment. The facility's policy on psychotropic medications emphasized considering these medications only after addressing various causes of behavioral symptoms, yet the lack of signed consent indicated a failure to adhere to this policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 70 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodland Springs Nursing Center | 1 mi | ★★★★★ | 4 | 1 |
| Ivy Creek Wellness & Rehabilitation | 1.3 mi | ★★★★★ | 1 | 0 |
| The Atrium Of Bellmead | 1.3 mi | ★★★★★ | 2 | 0 |
| Crestview Healthcare Residence | 2.9 mi | ★★★★★ | 1 | 0 |
| Lakeshore Village Nursing And Rehabilitation | 3.3 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St. Catherine Center.
100% money-back within 48 hours.
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.