Maison D'acadiens Care Center

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the discharge summary included a recapitulation of the resident's stay for 1 (Resident #66) of 3 closed records reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the necessary services to maintain good grooming. The facility failed to provide proper hair grooming for 1 (#54) of 17 sampled resident. The current census was 65.

Inspectors wroteBased on observation, and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents that received meals prepared by the kitchen. The facility census was 65.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by failing to ensure staff changed gloves and performed hand hygiene after touching contaminated areas during wound care for 1 (#10) of 2 (#4 and #10) residents observed for wound care.

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from insects. The deficient practice had the potential to affect 62 residents who resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure the Resident's right to formulate an advanced directive was properly reflected in the Resident's medical record for 1 (Resident #47) of 24 sampled residents. The facility failed to ensure all medical records regarding code status consistently reflected Resident #47's wishes to be a DNR (Do Not Resuscitate).

Inspectors wroteBased on interview and record review, the facility failed to ensure the NOMNC Form CMS-10123 (Notice of Medicare Non-Coverage) was provided to the resident and/or the resident's representative prior to discharge from Medicare Part A services for 2 (Resident #115 and Resident #116) of 2 sampled residents for Advanced Beneficiary Notice (ABN).

Inspectors wroteBased on interview and record review, the facility failed to document discharge planning for a resident who had expressed a desire to discharge. The facility failed to document a referral to an outside entity, and the responses received from the outside entity, for Resident #45. The total sample included 20 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene by failing to provide ADL care for 1 (Resident #54) of 24 sampled residents.

Inspectors wroteBased on observation, and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents that received meals prepared by the kitchen. The facility census was 62.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by: 1. failing to ensure staff performed hand hygiene between residents while feeding dependent residents; and 2. failing to ensure staff followed enhanced barrier precautions while providing direct patient care for Resident #23.

Inspectors wroteBased on record review and interview the facility failed to offer the Pneumococcal Vaccine on admit to the facility for 1 (#45) of 5 (#19, #45, #46, #54 and #60) residents sampled for Influenza, Pneumococcal and COVID-19 immunizations.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food was properly stored, prepared, distributed and served in accordance with professional standards for food service safety. The facility failed to ensure: 1. Expired/ outdated items were not available for resident consumption; 2. Dry food storage room was clean and free from residue from insects; 3. Kitchen utensils/ scoops were stored under sanitary conditions; 4. Refrigerated food contents were labeled and dated; 5. Kitchen linens were clean and properly stored. The total facility census was 63 residents.

Inspectors wroteBased on observations and interviews and record review, the facility failed to maintain an effective pest control program to ensure residents had a pest free environment. The deficient practice had the potential to affect all 63 residents that resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 2 (Resident #14 and Resident #43) of 2 sampled residents with MDS records over 120 days old.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Resident Assessment accurately reflected the cognition status for 1 (Resident #26) Resident. The sample size was 31. Review of Resident #26's EHR revealed an admit date of 12/14/2023 with diagnoses that included: Polyneuropathy, Spinal Stenosis, Urine Retention, Transient Paralysis, and Rhabdomyolysis. Review of the Resident #26's Quarterly MDS with an ARD of 12/21/2023 revealed he was interviewable with a BIMS of 10. Review of the BIMS conducted revealed: Repetition of Three Words-2 words repeated; Temporal Orientation (orientation to year, month, and day) missed by 1 year; What month are we in right now? accurate within 5 days; What day of the week is today? Correct; Going back What was the 3 words I asked you to repeat? answered after cueing; Able to recall blue- yes; Able to recall bed- yes. Total score- 10. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided to meet professional standards of practice as evidenced by failing to deliver oxygen therapy as ordered for 1 (Resident #2) of 1 resident reviewed for respiratory care. The facility census was 63 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide oral care and nail care to dependent residents for 3 (Resident #9, Resident #10, and Resident #26) of 3 (Resident #9, Resident #10, and Resident #26) residents sampled for ADL's

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of garbage and refuse properly. The total facility census was 63 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident assessments were electronically transmitted in a timely manner by failing to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (#1) of 3 (#1, #2, and #3) Residents reviewed for resident assessments.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure Resident's person centered plan of care were reviewed and revised to include a focus with interventions/tasks to address the Resident's risk of Elopement/Wandering for 2 (#2, and #3) of 3 (#1, #2, #3) sampled Resident's care plans reviewed.