Notre Dame Long Term Care Center

In the surveyor’s words

From the most serious findings on record at Notre Dame Long Term Care Center, in the surveyor’s own words.

• Actual harm, isolatedF656Sep 8, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Comprehensive Plan of Care (POC) indicated he/she required extensive assistance of two staff members, a gait belt and rolling walker for all transfers, the Facility failed to ensure staff implemented and followed interventions from his/her Plan of Care related to his/her individual needs during a transfer. When on 8/17/22 Certified Nurse Aide (CNA) #1 manually transferred Resident #1 by herself, from his/her wheelchair onto the toilet, and then using a mechanical lift by herself, CNA #1 then transferred Resident #1 from the toilet back to the wheelchair, and then from the wheelchair back to bed. […]

• Actual harm, isolatedF689Sep 8, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required two staff members assistance for transfers, the Facility failed to ensure he/she was provided with the required level of staff assistance to maintain his/her safety and prevent incident/accident resulting in injury. On 8/17/22, Certified Nurse Aide #1, who was assigned to care for Resident #1, physically (manually) transferred Resident #1 out of bed to his/her wheelchair to the toilet, she then used a mechanical lift to transfer him/her from the toilet back to the wheelchair, and then into bed, all of which she did by herself without another staff member present to assist her. […]

• Actual harm, isolatedF600Mar 15, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from physical abuse with use of a restraint, when Certified Nurse Aide (CNA ) #1 was witnessed by a staff member restraining Resident #1 by the wrists when Resident #1 became agitated and resisted care. Resident #1 was assessed after the incident and found to have sustained a skin tear to his/her the left upper arm and a bruise above the left wrist. CNA #1 also witnessed hitting the bathroom door in anger, in front of Resident #1, in an intimidating manner. […]

• No harm, potential for more than minimal, patternF761May 8, 2026

  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. […]

• No harm, potential for more than minimal, patternF755Dec 15, 2023

  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. […]