Notre Dame Health And Rehabilitation Center

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for respiratory care, the facility failed to obtain a physician's order for oxygen administration in a timely manner. The findings include: Resident #1 had diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, atrial fibrillation, shortness of breath, and dependence on supplemental oxygen. The nursing admission evaluation dated 4/29/2025 at 8:42 P.M. by Registered Nurse (RN) #1 identified that Resident #1 was alert, answered questions readily, and had quick comprehension. RN #1 identified Resident #1 was continent of bowel and bladder, used the toilet, required one person assistance for transfer, ambulation, personal hygiene, and limited assistance with dressing. The care plan dated 4/30/2025 identified Resident #1 has impaired gas exchange due to chronic obstructive pulmonary disease and respiratory failure with interventions that directed to evaluate pulse oximetry, evaluate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #42) reviewed for falls, the facility failed to develop and implement a comprehensive care plan for a resident who had a history of repeated falls on admission and was identified as a moderate fall risk. The findings include: Resident #42 was admitted to the facility on [DATE] with diagnoses that included syncope and collapse, Alzheimer's disease, and repeated falls. The admission fall risk assessment dated [DATE] identified Resident #42 had a history of 1 - 2 falls within the last 3 months, was taking diuretics, hypoglycemic agents, antihypertensives, and psychotropics more than 3 times weekly, had an inadequate vision pattern, and a gait analysis included: inability to independently come to a standing position, loss of balance while standing, requiring a hands-on assist to move from place to place, utilizing an assistive device, and had a decrease in muscle coordination. The fall risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #42) reviewed for falls, the facility failed to ensure quarterly fall risk assessments were completed, per the facility policy. The findings include: Resident #42 was admitted to the facility on [DATE] with diagnoses that included syncope and collapse, Alzheimer's disease, and repeated falls. The admission fall risk assessment dated [DATE] identified Resident #42 had a history of 1 - 2 falls within the last 3 months, was taking diuretics, hypoglycemic agents, antihypertensives, and psychotropics more than 3 times weekly, had an inadequate vision pattern, and a gait analysis included: inability to independently come to a standing position, loss of balance while standing, requiring a hands-on assist to move from place to place, utilizing an assistive device, and had a decrease in muscle coordination. The fall risk assessment further identified that Resident #42 was at a moderate risk for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility documentation, facility policy and interviews, the facility failed to ensure annual performance evaluations were completed for nurse aide staff for 2023. The findings included: During a review of performance evaluations for facility nurse aide staff on 8/26/24 for 2023 and 2024, the facility failed to provide any documentation of performance evaluations completed for NA #1 and NA #2 for 2023. Subsequent to this review, an additional request was made to the DNS provide additional annual performance evaluations for NA #1 and NA #2 for 2023. Interview with the DNS on 8/27/23 at 11:00 AM identified she was unable to locate any annual performance evaluations for nurse aide staff that had been completed in 2023. The DNS identified she was new to the facility and had completed annual evaluations for 2024 but was unable to locate any evaluations for nursing staff for 2023. The DNS further identified that she identified that the evaluations had not been completed and implemented an annual performance evaluation policy in 6/2024 to ensure that the annual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #39) reviewed for pressure ulcers, the facility failed to ensure appropriate infection control techniques were implemented during a dressing change for a resident on enhanced barrier precautions. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, bladder cancer, and dementia. The care plan dated 5/20/24 identified Resident #39 required a suprapubic catheter due to neurogenic bladder from bladder cancer. Interventions included to monitor for signs/symptoms of urinary tract infections. Further review of the care plan failed identify interventions related to potential alteration in skin integrity or enhanced barrier precautions. The quarterly MDS dated [DATE] identified Resident #39 had severely impaired cognition, was frequently incontinent of bowel and always incontinent of bladder and required maximal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 5 of 5 residents (Resident #3,14, 27, 30 and 209) reviewed for vaccinations, the facility failed to provide documentation that the resident or resident's representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization, and that the resident either received the pneumococcal immunization according to the CDC guidelines or did not receive the pneumococcal immunization due to medical contraindication or refusal. The findings include: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment, anxiety disorder, and cognitive communication deficit. Resident #3 had a resident representative who was identified as the responsible party, and Resident #3 was identified as being older than 65 years. The quarterly MDS dated [DATE] identified Resident #3's pneumococcal vaccination was up to date. The immunization record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 5 of 5 residents (Resident #3, 14, 27, 30 and 209) reviewed for COVID-19 immunizations, the facility failed to provide documentation that the resident, or resident representative was provided with current COVID-19 information regarding additional doses, including education and risks or potential side effects, or offered subsequent COVID-19 vaccinations. The findings include: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment, anxiety disorder, and cognitive communication deficit. Resident #3 had a resident representative was identified as the responsible party. Resident #3's immunization record identified the resident received a COVID-19 vaccine Step 1 on 6/22/22. No subsequent COVID-19 vaccinations, offerings or education were identified. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, alcohol dependence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility documentation, facility policy, and interviews the facility failed to ensure food items were rotated out of emergency stock to ensure freshness according to policy. An observation of emergency food storage during kitchen tour on 5/16/22 at 7:15 AM identified the following food items dated with black marker: 1.(12) cans puree chicken dated 4/29/21 in black marker 2. (6) cans puree green beans dated 4/29/21 in black marker 3. (6) cans puree beef dated 6/15/21 in black marker 4. (4) 6.75 lb cans of chili dated 6/7/21 in black marker 5. (4) 6/63 lb. cans beef stew dated 6/7/21 in black marker 6. (2) 6.75 lb. can ravioli dated 6/7/21 in black marker 7. (2) 6 lb. cans fruit cocktail dated 6/7/21 in black marker 8. (3) 6 lb cans pudding dated 6/7/21 in black marker 9. (2) 6 lbs. cans of green beans dated 6/7/21 in black marker An interview on 5/16/22 at 8:09 AM with the Food Service Director (FSD) identified emergency food items were dated in magic marker when placed into emergency stock and should be rotated into regular stock with 6 months of date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #6) reviewed for pressure ulcers, the facility failed to ensure a nutritional assessment was completed timely for a resident with a newly identified pressure ulcer. The findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, osteoarthritis and gastro-esophageal reflux disease (GERD). A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was severely cognitively impaired, required assistance with bed mobility, transfers and personal care, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers. A Resident Care Plan dated 2/23/22 identified a potential for skin breakdown, moisture associated skin damage, pressure ulcer development related to decreased mobility, incontinence of bowel and bladder. Interventions included house lotion to lower extremities as ordered,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #3) reviewed for falls, the facility failed to ensure the Resident Care Plan was reviewed/revised after Resident #3 fell, failed to accurately and completely complete every 15 minute checks, and failed to ensure timely Physical Therapy screens were completed on 2 occasions. The findings include: Resident #3 was admitted to the facility with diagnoses that included dementia, dysphasia, and anxiety. A Resident Care Plan dated 2/14/21 identified Resident #3 was at risk for falls related to a history of falls at home, falls in the facility, impaired cognition, lack of safety awareness and attempts to self-transfer. Interventions included to ensure the call light was within reach and encourage resident to use it, ensure that he/she is wearing appropriate footwear when ambulating or mobilizing in the wheelchair, follow fall protocol and to utilize a bed and chair alarm. On 5/20/21 every…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure outbreak testing for staff were followed in accordance with infection control practices and facility protocols. The findings include: Electronic (text) communication to the Food Service Director (FSD) and other staff dated 5/15/22 noted a staff member had tested positive for COVID-19, with a directive for all staff to come in to the facility for testing. An observation on 5/16/22 between 6:10 AM and 6:40 AM identified the FSD exiting out of the kitchen area, ambulating in the hallway and then entering staff development room to assist setting up a table. The FSD time sheet dated 5/16/22 identified he punched in at 5:15 AM and punched out at 7:30 AM. An interview on 5/16/22 at 7:47 AM with RN #1 identified she began her shift at 7:00 AM and began completing outbreak testing, (antigen testing for COVID-19) for staff as soon as they enter the building. RN #1 indicated staff were to be tested upon entering the building and before going to their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interview for 1 of 2 residents (Resident #33) reviewed for pressure ulcers, the facility failed to follow the plan of care related to an out of bed schedule. The findings include: Resident #33's diagnoses included Alzheimer's dementia and stage 3 pressure ulcer. The quarterly MDS dated [DATE] identified Resident #33 had severely impaired cognition and required extensive assistance with bed mobility and transfers. The care plan dated 6/27/19 identified Resident #33 had a potential for pressure ulcer development with interventions that included to provide a low air loss mattress, check every shift for functioning, turn and reposition every 2 hours and more often as needed and/or requested. Review of an undated nurse aide care card identified to limit Resident #33's sitting time to 1 hour. A weekly skin sheet dated 8/22/19 identified Resident #33 had a stage 3 sacral pressure ulcer that measured 1 cm x 1 cm x <0.1 cm.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, revies of the clinical record, facility documentation, facility policy, and interviews for 2 of 8 residents (Resident #17 and 33) reviewed for dining, the facility failed to provide adaptive equipment during dining. The findings include: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses that included right hand and shoulder contractures, anxiety and dementia. A communication to nursing from therapy form dated 12/17/18 directed Resident #17 to use a divided 3 compartment plate to assist with scooping food during meals. A physician's order dated 12/20/18 directed to provide Resident #17 a divided plate to assist with scooping food, to remain independent with self-feeding. The annual MDS dated [DATE] identified Resident #17 had severely impaired cognition and required extensive assistance with eating. The care plan dated 8/19/19 identified Resident #17 had a self-care deficit. Interventions included to take Resident #17 to the dining room for lunch and supper, allow the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.