Notre Dame Long Term Care Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.