Notre Dame Long Term Care Center

Based on observations, and interviews, the facility failed to ensure staff stored and labeled all drugs and biologicals in accordance with accepted professional standards of practice, as required, for two (Cuvilly Unit High Side and Cuvilly Unit Low Side) of the three medication carts reviewed.Specifically, for the Cuvilly Unit High Side medication cart and the Cuvilly Unit Low Side medication cart, the facility failed to ensure that medications were appropriately stored and labeled in the two medication carts when loose, unlabeled pills were observed in both medication carts. Findings include:Review of the facility policy titled Medication Cart Cleaning, dated December 2023, included:-All Medication Carts will be cleaned and organized weekly on the 11-7 shift On 5/6/26 at 8:20 A.M., the surveyor and Unit Manager (UM) #3 observed in the Cuvilly Unit High Side medication cart thirty-five loose pills, paper remnants and elastics, as well as powder in the corners of the drawer that holds resident specific medication cards. During an interview at the time, UM #3 said the concern would…

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, interviews, and record review, the facility failed to ensure that a person-centered care plan, relative to eating assistance and supervision, was implemented for one Resident (#12) out of a total sample of 24 residents. Specifically, for Resident #12, the facility failed to implement supervision by one staff and assist of one staff as needed to set up meals as required, when the Resident experienced a significant weight decline and was care planned for feeding assistance and supervision.Findings include:Review of the facility policy titled Meal Serving, revised February 2012, included but was not limited to:*All residents able to receive oral feeding are properly positioned to facilitate eating. Any resident requiring assistance with meals receives help as needed. Adaptive equipment is provided as ordered to assist individual residents as needed.-Residents who are able to eat outside of their rooms are served in the dining areas.-Residents incapable of feeding themselves will be assisted…

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 observations, interviews, and record review, the facility failed to ensure that medications were administered per professional standards of practice for two Residents (#90 and #104) out of a total sample of 24 residents, resulting in two significant medication errors. Specifically, 1.for Resident #90, the facility staff failed to obtain a blood pressure reading per the Physician's order, prior to administering Amlodipine Besylate (medication used to treat high blood pressure) and to hold (not give) the Amlodipine Besylate medication for a Systolic Blood Pressure (SBP- top number of a blood pressure reading) that measured less than 110 millimeters of Mercury (mmHg) in accordance with the Physician's order, placing the Resident at risk for cardiac compromise, hypotension (extremely low blood pressure) and related complications such as dizziness, fainting and vision changes. 2.for Resident #104, the facility staff failed to hold Amlodipine Besylate, Torsemide (diuretic medication used to treat fluid retention and high blood pressure), and Valsartan (medication used to treat…

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, and interview, the facility failed to ensure that a Licensed Nurse (Nurse #2) had the specific competencies and skill sets necessary to provide wound care for one Resident (#84). Specifically, the facility failed to ensure that Nurse #2 had the knowledge, competency and skills relative to infection control practices when providing wound care for Resident #84. Findings include: Review of the facility policy titled, Competency, undated, indicated: -Facility would ensure all nursing staff maintain high standards of patient care and safety. -Each nurse is responsible for maintaining their competency through training, evaluation, and professional development. -Nurses are required to periodically demonstrate continued proficiency in their roles through assessments, evaluations or skills check. -Common areas assessed include clinical skills, patient care, medication administration, infection control practices, communication skills and ethical decision-making. -Nurses undergo regular performance evaluations where their competencies are assessed by supervisors or…

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, record review, and interview, the facility failed to provide Adaptive Eating Equipment for one Resident (#75) out of a total sample of 23 residents. Specifically, the facility failed to provide built-up handled adaptive utensils for meals as required to preserve Resident #75's current level of function during meals. Findings include: Review of the facility policy titled Adaptive Equipment, undated, indicated: -Adaptive equipment for meal service in a nursing home is designed to help residents with varying physical abilities eat independently, safely, and comfortably. -Built-up Handle Utensils: These have thicker handles to make gripping easier for people with limited hand strength or dexterity . Resident #75 was admitted to the facility in April 2021 with diagnoses including Unspecified Dementia and Muscle Weakness (Generalized). Review of the Resident's Activities of Daily Life (ADL) care plan, revised 6/3/24, included an intervention for eating of .Black Silverware .during meals. Review…

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, interview, and record review, the facility failed to adhere to infection control standards of practice for two Residents (#103 and #84) out of a total sample of 23 residents, increasing the risk of contamination and the spread of infection to the Residents and other residents within the facility. Specifically, the facility failed to: 1. For Resident #103, ensure that staff appropriately followed Enhanced Barrier Precautions (EBP's: the use of protective gowns and gloves during high contact care activities that may provide opportunity for transmission of medication resistant organisms through staff hands and/or clothing), while providing high contact care. 2. For Resident #84, ensure that staff adhered to infection control standards and hand hygiene practices while performing wound care. Findings include: Review of the facility policy titled Enhanced Barrier Precautions, dated 2001, revised August 2022, included but was not limited to: -Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of…

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 records reviewed and interviews, for one of three sampled residents (Resident #1), who had recently sustained a fractured left tibia (lower leg) of unknown origin and whose comprehensive plan of care indicated he/she required assistance of two staff members for bed mobility, the Facility failed to ensure staff consistently implemented followed this interventions, therefore placing the resident at risk for potential injury. Findings include: Review of the Facility's policy, titled Care Plans- Comprehensive, dated 10/2010, indicated an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs would be developed for each resident. Resident #1 was admitted to the Facility in June 2021, diagnoses included poly-osteoarthritis (multiple joints with arthritis that occurs when flexible tissue at the ends of bones wears down) and frontotemporal neurocognitive disorder (dementia affecting the front and temporal lobes of the brain). Review of Resident #1's Quarterly Minimum Data Set…

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, policy review and interview, the facility failed to accurately and safely ensure that routine and emergency medications and pharmaceutical services were provided to meet the needs of each facility resident. Specifically, the facility staff failed to ensure that: 1. expired medications were removed from the medication carts on two units (West and Harmony Village) out of three units observed. 2. three open medication Emergency Box Kits on one unit (South) were re-ordered as required. Findings include: 1. Review of the facility policy titled, Medication Storage in the Facility, dated 2017, indicated: -Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to the procedures for medication disposal. -All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. Review of the facility polity titled, Medication Cart Cleaning, undated, indicated: -All medication Carts…

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, interview, policy and record review, the facility failed to adhere to infection control standards for three Residents (#98, #171 and #70) who tested positive for COVID-19, on three out of three units observed, and for one Resident (#75) during treatment and care of a wound, out of a total sample of 24 residents. Specifically, the facility staff failed to ensure: 1. For Residents (#98 and #171), that staff performed appropriate hand hygiene and wore personal protective equipment (PPE) when caring for COVID-19 positive residents, to mitigate the spread of infection during a COVID-19 outbreak in the facility. 2. For Resident #70, that staff implemented Isolation Precautions and posted appropriate signage outside of the Resident's room after they tested positive for COVID-19. 3. For Resident #75, that the staff performed hand hygiene during a pressure ulcer wound care procedure. Findings include: Review of the facility policy for Infection Control Personal Protective Equipment Policy, last…

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 record review, policy review and interview, the facility failed to execute Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) for one Resident (#318), out of a total sample of 24 residents. Specifically, for Resident #318, the facility staff failed to ensure that Advanced Directives on a completed (prior to facility admission) Massachusetts Medical Order for Life-Sustaining Treatment (MOLST) form were honored per the Resident's wishes. Findings include: Review of the facility policy for MOLST, undated, indicated that Residents admitted with a completed MOLST form: -Upon admission the nurse will note the existence of the MOLST FORM and review the form for completeness. A completed MOLST is a legal medical order and is immediately actionable. -The MOLST should be copied, and the date of the copy written on the form. This copy and the original…

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, interview, record and policy review, the facility failed to implement an individualized plan of care for one Resident (#5), out of a total sample of 24 residents. Specifically, for Resident #5 who was identified as being at nutritional risk, the facility staff failed to ensure that weekly weights were obtained per Physician order and the nutrition care plan. Findings include: Review of the facility's policy titled, Weight Monitoring Program, revised 1/12, indicated: -There will be a systematic and interdisciplinary approach to monitoring resident weights. -All new admissions will be weighed on admission and at least weekly unless the Physician order states otherwise. -When transferring residents between units, resident weight will be re-weighed/reconciled in comparison to the previous weight whenever necessary. Resident #5 was admitted to the facility in March 2023 with diagnoses including Abdominal Aortic Aneurysm without rupture (AAA- an enlargement of the aorta [the main blood vessel that delivers blood to the body] at the level of the abdomen), Acute Kidney…

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, interviews, record and policy review, the facility failed to ensure that required Physician orders were in place for the administration of Oxygen therapy for one Resident (#55), of three applicable residents receiving Oxygen, out of a total sample of 24 residents. Specifically, the facility staff failed to ensure that Physician orders that included the concentration of Oxygen, the method of Oxygen delivery, the frequency of use and the indications for supplemental Oxygen were in place for Resident #55. Findings include: Review of the facility policy titled Oxygen Administration, revised October 2010, indicated the purpose of the procedure was to provide guidelines for safe Oxygen administration and included: -verify that there is a Physician's order for the procedure -review the Physician's orders or facility protocol for Oxygen administration -review the resident's care plan to assess for any special needs Resident #55 was admitted to the facility in August 2023 with a diagnosis of…

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, record review and interview, the facility failed to provide accomodations to meet the specific dietary needs of one Resident (#318) out of a total sample of 24 residents. Specifically, the facility staff failed to accommodate the individualized request for Resident #318 to have his/her food items cut-up prior to receiving his/her meals, as the Resident had an arm injury that made it difficult to be independent with cutting food items. Findings include: Review of the facility policy titled Interdepartmental Notification of Diet (Including Changes and Reports), revised October 2008, indicated the following: -Nursing Services shall notify the Food Services Department of a resident's diet orders, including any changes in the resident's diet, meal service, and food preferences. -When a new resident is admitted , or a diet has been changed, the Nurse Supervisor shall ensure that the Food Services Department receives written notice of the diet order. Resident #318 was admitted to the facility in December 2023 with a diagnosis of Displaced Fracture of Surgical Neck of…

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 interview, record and policy review, the facility failed to ensure the policy relative to Pneumococcal Vaccinations was revised and up to date with current Centers of Disease Control and Prevention (CDC) recommendations.The facility also failed to provide the Pneumococcal Vaccine for one Resident (#27) and assess two Residents (#74 and #83), out of five applicable residents, for the eligibility to receive or decline the Pneumococcal Vaccine, placing them at risk for contracting facility acquired Pneumonia. Specifically, the facility failed to: 1) ensure that staff administered the Pneumococcal Vaccine after consent was obtained and there was no history of previous Pneumococcal Vaccinations for Resident #27. 2) provide education on the Pneumococcal Vaccine, assess for eligibility and offer the vaccine based on the CDC recommendations for Residents #74 and #83. Findings include: Review of the facility policy titled Pneumococcal Vaccination, revised 11/25/19, indicated: -There were two types of…

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.