Inspection Reports for
Holy Cross Village at Notre Dame Inc

The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included unsecured furniture in a corridor, unsealed penetrations in smoke barrier walls, and smoke barrier doors that did not properly restrict smoke movement.

Complaint IN00442671 was investigated and no deficiencies related to the allegations were cited. The unrelated deficiency involved a fall due to improper transfer of Resident E with a mechanical lift.

No deficiencies related to the complaint allegations were cited. An unrelated deficiency was cited involving failure to transfer a dependent resident with a mechanical lift according to physician orders, resulting in a fall and a left shin fracture. The deficient practice was corrected prior to the survey.

The complaint investigation found that on 7/27/24, Resident E was lowered to the floor during a transfer without use of the mechanical lift as ordered. The resident sustained a fracture to the left distal tibial metaphysis and fibular shaft. Staff failed to notify management promptly. Corrective actions were taken including staff discipline and education.

The facility failed to follow the mechanical lift transfer protocol for Resident E, resulting in a fall and a left shin fracture. The incident was self-reported, and corrective actions including staff education and disciplinary measures were implemented prior to the survey date, resolving the deficiency.

Complaint IN00435850 was related to an allegation of physical abuse by a staff member toward Resident C. The facility investigated the allegation but did not substantiate it and did not report it as abuse, consulting lawyers who believed it was not abuse but gossip.

The facility failed to report an allegation of abuse for one resident (Resident C). The allegation was investigated and deemed unsubstantiated within two hours, and the facility did not report it as abuse based on legal consultation.

This citation relates to Complaint IN00435850. The allegation involved a staff member purposely pushing a resident out of bed causing the resident to hit her head. The facility did not substantiate or report the abuse, consulting lawyers who concluded it was not abuse.

The facility failed to report an allegation of abuse for one resident after investigating and determining there was no abuse, consulting lawyers who also concluded it was not abuse but gossip. The facility did not follow its policy requiring timely reporting of alleged abuse to proper authorities.

The facility was found not in compliance with Life Safety Code requirements, including deficiencies related to sprinkler system installation and maintenance, fire hydrant inspections, ground fault circuit interrupter (GFCI) maintenance, and improper use of extension cords. Corrective actions were taken during the survey and systemic changes were planned to prevent recurrence.

The facility was found deficient in revising care plans timely, preventing pressure ulcers, providing timely incontinent care, ensuring proper medication storage and labeling, and maintaining food safety and sanitation standards in the kitchen and pantry.

The facility was found deficient in multiple areas including care plan revisions, pressure ulcer prevention, incontinent care, medication storage and labeling, food safety and sanitation, fire and disaster preparedness drills, and semi-annual resident evaluations.

The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included obstructions in means of egress, incomplete preventative maintenance documentation for smoke alarms, incomplete fire pump system maintenance, doors lacking positive latching hardware, missing annual fire door inspections, combustible materials stored too close to oxygen storage, and other fire safety code violations.

The facility was found deficient in multiple areas including resident dignity and self-determination, care plan updates, ADL care, accident prevention, respiratory care, food service sanitation, emergency record completeness, and maintenance of building systems.

The facility was found deficient in multiple areas including failure to provide adequate clothing and dignity for residents, failure to provide showers per resident preferences, failure to update care plans timely, inadequate assistance with activities of daily living such as bathing and nail care, failure to ensure safety measures during salon services for residents on oxygen, improper storage of respiratory equipment, and unsanitary food service practices.

The facility was found not in compliance with Emergency Preparedness requirements due to lack of an evacuation policy and procedure, and not in compliance with Life Safety Code requirements due to a corridor door that did not latch properly and had excessive clearance at the bottom, potentially affecting staff safety.