Notre Dame Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Notre Dame Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 9, 2025

  Based on record review, facility documentation review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident with a diagnosis of dementia and a known fall risk was properly supervised and failed to ensure the resident was not left alone in the bathroom, to prevent a fall with injury. The findings include:Resident #1 had a diagnosis of dementia. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severely impaired cognition, had no behaviors, and was dependent on staff assistance for toileting and transfers. The Resident Care Plan (RCP) dated 11/12/2025 identified a risk for falls and self-care deficit. […]

• No harm, potential for more than minimal, widespreadF851Apr 21, 2026

  Based on review of facility documentation and interviews, the facility failed to ensure accurate staffing data was entered in the Payroll Based Journal (PBJ) during FY Quarter 3 2025 (April 1 -June 30). The findings include: Review of the PBJ Staffing Data Report dated FY Quarter 3 2025 (April 1 -June 30) submitted to Center for Medicare and Medicaid (CMS) identified the facility triggered no RN hours and no licensed nurse coverage 24 hours/day from 4/1/25 through 6/30/25 Review of the Daily Staffing dated 4/1/25 through 6/30/25 identified the facility did have RN coverage and licensed nurse coverage 24 hours a day. […]

• No harm, potential for more than minimal, patternF812Apr 21, 2026

  Based on observation, review of the clinical record, facility documentation, facility policy, and interviews, the facility failed to ensure that the temperature logs for the sanitizing solution, refrigerators and freezers were documented accurately for November 2025 and December 2025; and failed to ensure that food temperatures were monitored and documented; and failed to ensure that tracking logs for the sanitizing solution, refrigerators, and freezers, and resident meals were completed in their entirety and daily. The findings include:a. Observation and interview on 4/18/26 at 7:15 AM with the Dietary Director identified an issue with the sanitizing solution strips used to check the quaternary sanitizing solution concentrations. […]

• No harm, potential for more than minimal, patternF880Apr 21, 2026

  Based on observation, review of the clinical record, facility documentation, facility policy, facility assessment and interviews for 1 resident (Resident #6) reviewed for pressure ulcers, the facility failed to ensure personal protective equipment (PPE) was worn while providing care in accordance with infection control standards for a resident on enhanced barrier precautions (EBP), failed to ensure monthly infection surveillance data was tracked from 1/1/26 through 4/19/26 and failed to ensure complete and accurate clinical data was included in 2 of 3 residents (Residents #1 and 46) Individual Infection Reports that were reviewed. The findings include: 1. […]

• No harm, potential for more than minimal, patternF881Apr 21, 2026

  Based on review of the clinical record, facility documentation, facility policies, and interviews the facility failed to ensure the infection surveillance system tool (McGeer Criteria) was utilized prior to initiating antibiotics and failed to ensure antibiotic time outs were completed 72 hours after the initiation of antibiotics, per the facility policy for 3 of 3 resident (Residents #1, 15, and 46), and failed to ensure a system was in place to monitor antibiotic usage data. The findings include: 1a. Resident #1 was admitted to the facility in May 2025 with diagnoses that included hydronephrosis and a history of other infectious and parasitic diseases. […]