Bonne Vie

Inspectors wroteBased on interview and record review, the facility failed to assess each resident once every three months, using the quarterly review instrument specified by the state and approved by CMS, for 1 of 26 residents (Resident #1) reviewed for quarterly assessments. The facility failed to ensure Residents #1 had a quarterly MDS assessment completed within three months from the previous assessment. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions.

Inspectors wroteBased on interview and record reviewed, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 of 26 residents records reviewed for MDS assessments. (Residents #127) The facility failed to ensure the discharge MDS assessment was completed and transmitted as required for Resident #127. This failure could place residents at risk for MDS assessments not being transmitted and not receiving care and services as needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #21) reviewed for activities of daily living. The facility failed to clean, trim, and clip Resident #21's fingernails. This failure could place residents at risk of not receiving care and services to meet their needs, feelings of poor self-esteem, and lack of dignity and health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 8 medication carts (Medication cart D) reviewed for medication storage. The facility failed to ensure the narcotic box was attached and secured with double locks in Medication cart D. This failure could place residents at risk for drug diversion.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (Resident #1) reviewed for quality of care. The facility failed to conduct a comprehensive bowel elimination assessment and document 's bowel pattern in the electronic health record for 2 of 3 shifts on 11/28/2025 and 2 of 3 shifts on 11/29/2025. This failure could place residents at risk for not receiving bowel assessments leading to fecal impactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental, and psychosocial needs for 3 of 24 residents reviewed for care plans. (Residents #28, #42, & #87) The facility did not include interventions and goals for Resident #28's hospice care plan. The facility did not have a care plan to address Resident #42's use of Trazadone. The facility did not have a care plan to address that Resident #87 was PASRR positive and refusing services. These failures could place residents at risk of not having their individual needs met and not receiving needed services.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure LVN A did not verbally abuse Resident #1 when she yelled, screamed, and made intimidating remarks at the resident on 12/05/2023. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 15 residents (Resident #1 and #2) reviewed for infection control. 1. CNA A failed to wash or sanitize her hands or change gloves while performing incontinent care for Resident #1. 2. CNA D failed to wash or sanitize her hands or change gloves while performing incontinent care for Resident #2. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on record review and interview, the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements. The facility did not ensure the arbitration agreement contained the required element of informing residents of their right to rescind in 30 calendar days of signing the agreement. This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, cause a loss of their legal rights, and cause negative psychological issues.

Inspectors wroteBased on interview and record reviewed, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 of 25 residents records reviewed for MDS assessments. (Residents #35) The facility did not ensure the discharge MDS assessment was completed and electronically transmitted as required for Resident #35. This failure could place residents at risk of not having their assessments transmitted timely.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 24 residents reviewed for indwelling catheters. (Resident #63) The facility failed to prevent Resident #63's urinary catheter drainage bag from touching the floor. This failure could place residents at risk for urinary tract infections.