Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maison Du Monde Living Center during CMS and state inspections, most recent first.
Failure to Inventory and Label Resident Clothing: A resident admitted for respite care had clothing missing when his RP picked him up, including pajamas, T-shirts, and socks. The facility policy required resident belongings to be inventoried and documented on admission, but staff did not inventory or label the resident’s clothing, and an S4AD confirmed she was responsible for the missed inventory and labeling.
Failure to provide ADL assistance and hygiene care: A resident with blindness and incontinence needs did not receive the required bath/shower or peri-care support during a short respite stay. The resident was found dirty, malodorous, and soiled with urine and stool, and staff interviews confirmed the missed shower, lack of a bed bath, and failure to notify the assigned LPN.
Failure to post daily nurse staffing information. Facility observations found no staffing sheet posted in a prominent, readily accessible location for residents and visitors. The required posting did not include the facility name, date, census, or the total number and actual hours worked by staff responsible for resident care. An interview with the Benefits Coordinator confirmed she was responsible for calculating and posting the staffing hours and that it had not been done daily.
A resident with moderate hearing impairment and intact cognition, care planned as needing hearing aids, did not receive appropriate assistive devices after the facility failed to follow up with community resources. Social services knew the resident could not afford a hearing program’s application fee and that referrals had been made by an ENT to outside providers for assistance with hearing devices, including an evaluation that was never scheduled. Despite this and the facility policy assigning social services responsibility for obtaining outside services, the Social Services Director did not follow up with the community providers or seek alternative assistance after family involvement lapsed, leaving the resident waiting for hearing aids for months.
Infection Control Failures During Wound Care, Perineal Care, and Linen Storage: Staff did not use EBP gowns during wound care for a resident with a draining diabetic foot ulcer, a CNA reused the same wipe during perineal care for a resident with a UTI history and urinary incontinence, and clean washable bed pads were observed drying in the soiled linen room near dirty water and soiled laundry items.
Two residents with cognitive and psychiatric conditions engaged in repeated physical altercations on consecutive days after an accusation of stolen soda. On the first day, a resident using a walker accused a wheelchair user of theft, after which the wheelchair user rammed the walker and struck the other resident's leg while a CNA was pushing her away. On the next day, the resident with the walker kicked the wheelchair user in the leg as she passed in the hallway, later admitting she did so in retaliation for the prior day's incident. An LPN documented both events, and the administrator was notified, but the facility did not effectively prevent or protect the residents from physical abuse by each other, contrary to its abuse prevention policy.
A resident was discharged from the facility without a required discharge summary being completed, contrary to the facility’s own policy that mandates a discharge summary and post-discharge plan for anticipated discharges to a private residence or another nursing care facility. Record review showed the absence of any discharge summary in the resident’s medical record, and the SSD confirmed during interview that no discharge summary had been completed.
A facility failed to report resident-to-resident physical abuse to the State Survey Agency within the required timeframe. Two residents were involved in repeated altercations in which one resident struck the other and was later kicked in retaliation; the ADM was notified at the time of each incident, but the incidents were not reported to the state agency. One resident had dementia with behavioral disturbances and moderate cognitive impairment, while the other had bipolar disorder and depression with psychotic features.
Failure to provide needed grooming and nail hygiene: A resident with dementia and total dependence for personal hygiene was observed in bed with long, dirty fingernails and a thick brown substance under one fingernail on repeated observations. The CNA did not clean the nails or notify the treatment nurse of any refusal, and the ADON/IP confirmed the findings.
The facility failed to document and investigate complaints about inconsistent ice distribution voiced during resident council meetings. Despite the facility's policy requiring investigation and reporting of grievances, the Activity Director did not document the complaints, and the CNA Supervisor was unaware of them. Residents expressed dissatisfaction with the inconsistency, highlighting a deficiency in addressing resident concerns.
The facility failed to notify a physician of abnormal CBG levels for a resident with diabetes and did not document a choking incident in another resident's care plan. The first resident had multiple instances of high CBG levels without physician notification, while the second resident, who was cognitively intact, experienced a choking incident that was not addressed in their care plan. Both deficiencies were confirmed by facility staff.
The facility failed to follow recipes for pureed diets, affecting 12 residents. Observations showed cooks preparing pureed meals without measuring ingredients, resulting in improper consistency. Dietary staff lacked training and access to recipes, as confirmed by the RD. This deficiency could impact residents' nutritional intake.
The facility failed to meet professional standards for two residents receiving hospice care. One resident's hospice binder was not updated with current nurse visit notes and certification, and staff were unclear about responsibility for updates. Another resident experienced multiple high blood sugar levels without the hospice agency being informed, as confirmed by the Corporate Nurse and Hospice Agency Director of Nursing.
A facility failed to ensure a resident was safe to self-administer medication, as required by policy. The resident, with moderate cognitive impairment, was observed with medication at her bedside without an assessment or care plan for self-administration. An LPN confirmed leaving the medication, and the DON acknowledged the lack of necessary documentation, indicating a failure to adhere to the facility's policy.
The facility failed to report injuries of unknown source for two residents with severe cognitive impairment. One resident was found on the floor with a left arm fracture and a UTI, while another was found with a head bruise and a left wrist fracture. Both incidents were not reported to the state agency as required.
The facility failed to notify the State LTC Ombudsman of facility-initiated transfers for two residents, as required. A resident with Alzheimer's and another with dementia were transferred to the hospital multiple times, but these transfers were not recorded in the Emergency Transfer Log. The BOM, responsible for the log, was unaware that even short-term transfers needed to be reported, potentially affecting the entire census of 112 residents.
A facility failed to administer enteral feeding at the ordered rate for a resident with Alzheimer's, dementia, and a gastrostomy. The policy required checking the rate against the order, but an LPN confirmed the feeding was running at 45 ml/hour instead of the ordered 44 ml/hour, potentially affecting other residents with tube feedings.
A facility failed to maintain accurate medical records by not ensuring a resident's care plan reflected the need for weekly weight monitoring, despite significant weight loss and a low BMI. The care plan inaccurately documented monthly weighing, which was confirmed by an MDS/LPN during a review. This discrepancy could potentially affect the facility's entire census.
A facility failed to ensure proper use of PPE during biohazard trash removal. A Treatment Nurse was observed handling a soiled glove and biohazard bag without gloves and placed the bag on a treatment cart. The DON confirmed the nurse should have used PPE and not placed the bag on the cart.
A facility failed to ensure proper monitoring and reporting of wound care, leading to an Immediate Jeopardy situation. A resident with multiple health issues, including Peripheral Vascular Disease and Diabetes, experienced a significant deterioration in a right foot wound and developed a new wound on the left foot, both of which became infested with maggots. LPNs conducted assessments without oversight from a registered nurse, resulting in a lack of notification to the physician about the worsening condition.
The facility failed to provide an effective wound prevention program due to the lack of RN oversight in monitoring weekly body/skin assessments and wound evaluations conducted by LPNs. This deficiency led to an Immediate Jeopardy situation when a resident's deteriorating foot wounds were not reported, resulting in maggot infestation.
A facility failed to notify a resident's responsible party and healthcare providers about a worsening right foot wound. The resident had multiple health issues, and the wound significantly increased in size over several weeks. Despite the deterioration, there was no documentation of notification, and interviews confirmed the responsible party and nurse practitioner were not informed. The facility's policy lacked clarity on reporting responsibilities.
Failure to Inventory and Label Resident Clothing
Penalty
Summary
The facility failed to ensure a resident’s belongings were secured by not inventorying, documenting, and labeling clothing upon admission for one resident. The facility policy titled Personal Property stated that resident belongings are to be treated with respect and that the resident’s belongings and clothing are to be inventoried and documented upon admission and updated as necessary. Resident #1 was admitted for respite care and had diagnoses including malignant neoplasm of colon, secondary malignant neoplasm of the retro peritoneum and peritoneum, bipolar disorder, and unspecified pain. The resident’s responsible party reported that when she returned to pick him up, he was missing 3 pairs of pajamas, 4 t-shirts, and 3 pairs of socks. A staff member stated that another staff member was responsible for inventorying and labeling the resident’s clothing and did not do so, and that the resident’s clothing was missing. The staff member responsible for inventorying and labeling confirmed she should have gone into the resident’s room, completed an inventory of his clothing, and labeled the items.
Failure to Provide ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to ensure a resident who required assistance with activities of daily living received the needed help to maintain grooming and personal hygiene. The resident was admitted for respite care with diagnoses including malignant neoplasm of the colon, secondary malignant neoplasm of the retroperitoneum and peritoneum, bipolar disorder, pain, and blindness. The resident’s MDS indicated he required set up or clean up assistance with bathing and personal hygiene, and his care plan directed staff to assist with ADLs, bathe and shampoo hair, encourage clothing changes, and provide peri-care as needed because of blindness, multiple disease processes, and occasional bowel and bladder incontinence. The resident’s responsible party stated that when she picked him up after the respite stay, he was dirty, smelled of urine, had incontinent underwear full of urine and stool stains, and wet pants, and the facility could not provide documentation that he received a bath during the stay. The bath/shower record showed no documented shower or bath during the admission. Staff interviews confirmed the missed shower on the scheduled day: the shower aide stated the resident was supposed to be showered but was not brought to the shower room, the CNA acknowledged the resident did not receive a shower and that she should have offered a bed bath but did not, and the assigned LPN was not informed. The DON stated both staff members should have reported the missed bath to the nurse, and the CNA supervisor stated there was no reason the resident should not have at least received a bed bath.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nursing staffing information in a prominent place readily accessible to residents and visitors. The required posting was not observed during three separate facility-wide observations on 01/27/2026 at 8:39 a.m., 10:30 a.m., and 12:21 p.m. The report states that the facility census was 119 and that the staffing posting did not include the facility name, date, census, or the total number and actual hours worked by staff responsible for resident care. During an interview on 01/27/2026 at 12:30 p.m., S7BenCoor, the Benefits Coordinator, confirmed she was responsible for calculating and posting the nurse staffing hours and acknowledged that it had not been done and should be done daily.
Failure to Follow Up on Community Resources for Hearing Aids
Penalty
Summary
The facility failed to ensure a resident received proper treatment and assistive devices to maintain hearing abilities by not following up with community resources. The resident, who was cognitively intact with a BIMS score of 13 and had moderate hearing difficulty requiring increased volume and distinct speech, had a care plan problem for altered communication related to being hard of hearing and recurrent cerumen impaction, with a noted need for hearing aids. The care plan documented that paperwork for hearing aids had been sent with the family but not returned due to financial issues. In an interview, the resident reported having waited months for hearing aids and stated the facility told her they were waiting on a company to get the devices, while the surveyor had to speak very loudly for the resident to hear. Record review and interviews with the Social Services Director (SSD) showed that the resident had been seen by an ENT specialist and was recommended for a hearing program that required an application fee the resident could not afford. The SSD documented that the ENT office stated the resident could not participate in the program without paying the fee and that the resident was referred to another community provider for assistance with hearing devices. The SSD later learned that this community provider saw the resident and referred her to a second provider for an evaluation to assist with obtaining hearing aids, but the evaluation was never scheduled. The SSD acknowledged she did not follow up with either community provider after communication with the family ceased and did not pursue other assistance or resources for hearing aids from that time until questioned by the surveyor, despite facility policy assigning social services responsibility for making referrals and obtaining needed services from outside entities.
Infection Control Failures During Wound Care, Perineal Care, and Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when staff did not use Enhanced Barrier Precautions during wound care for a resident with a left heel diabetic foot ulcer. The resident was admitted with diagnoses including type 2 diabetes mellitus, an unspecified open wound of the left foot, and chronic kidney disease stage 3. The active wound order directed cleansing of the left heel diabetic foot ulcer and application of medihoney, calcium alginate, and a cover dressing as needed for soilage or removal. A wound care progress note documented moderate serous-sanguineous exudate from the left heel wound, but during observation of wound care, the treatment nurse and CNA performed the procedure without gowns. The treatment nurse stated the resident was not on EBP because the resident was not on the list provided by the Infection Preventionist, and the Infection Preventionist later confirmed the resident had a diabetic foot ulcer with drainage and should have been on EBP precautions. The facility also failed to use proper infection control technique during perineal care for a resident with a history of urinary tract infections, dysuria, chronic kidney disease, and occasional urinary incontinence. The resident’s care plan directed staff to assist with perineal care as needed and to assist with personal hygiene/peri-care due to bladder accidents and use of pull-ups. During observation, a CNA donned gloves, applied perineal cleanser to a wipe, and wiped the resident’s perineal area from front to back, then used the same wipe again to wipe the area a second time from front to back. The CNA confirmed she should have discarded the wipe and used a new one each time, and the Infection Preventionist confirmed the same wipe should not have been used multiple times. The facility also failed to properly separate clean and soiled linens when clean bed pads were observed in the soiled linen room. During observation of the laundry department, blue multi-use washable bed pads were hanging on a metal clothesline in the soiled linen room, next to the washing machines and directly above a mop bucket containing dirty water. One bed pad was touching the outside of the door and the handle of the washing machine. The Housekeeping Supervisor stated the bed pads were resident bed pads that had been washed and were hanging to dry, and acknowledged they should probably not be hanging in the soiled linen room. The Infection Preventionist also confirmed the clean bed pads were hanging in the soiled linen laundry room and should have been in the clean linen laundry room.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse during resident-to-resident altercations on consecutive days. Facility policy on abuse prevention states that residents have the right to be free from abuse, including physical abuse, and that administration will protect residents from abuse by anyone, including other residents, and protect residents during abuse investigations. Despite this policy, one cognitively intact resident with bipolar disorder and depression with psychotic features (Resident #81) and another resident with Alzheimer's disease, dementia with behavioral disturbances, major depressive disorder, and anxiety disorder (Resident #2) engaged in physical aggression toward each other without effective prevention of further contact. On the first day, documentation and interviews showed that Resident #81 was walking in the hallway with a walker when Resident #2, in a wheelchair, passed by. Resident #81 accused Resident #2 of stealing her soda, and Resident #2 then ran her wheelchair into Resident #81's walker. A CNA intervened and began pushing Resident #2 back to her room, during which Resident #2 reached out and hit Resident #81 on the leg. Nursing notes and the facility incident report documented that both residents were then taken to their rooms and that no injuries were observed at that time. The LPN and CNA interviews were consistent in describing that Resident #2 physically struck Resident #81 during the separation. On the following day, the same LPN documented that Resident #2 was again propelling herself in the hallway when Resident #81 came out of her room and kicked Resident #2 in the leg as she passed. Resident #2 yelled out in response, and when questioned, Resident #81 admitted to kicking Resident #2, stating she did so because Resident #2 had hit her the previous day and stolen her soda and that she was not sorry. The LPN assisted Resident #2 back to her room while Resident #81 remained in her room to finish breakfast. The administrator confirmed being notified of both physical altercations at the times they occurred and that there were no injuries, but the incidents demonstrated that the facility did not effectively protect either resident from physical abuse by the other resident as required by its abuse prevention policy.
Failure to Complete Required Discharge Summary for Discharged Resident
Penalty
Summary
The facility failed to complete a required discharge summary for one of three closed records reviewed. The facility’s policy, last reviewed on 04/09/2025, states that when a discharge is anticipated to a private residence or another nursing care facility, a discharge summary and post-discharge plan must be developed to assist the resident’s adjustment, and that a copy of the discharge summary must be provided to the resident, the receiving facility, and filed in the resident’s medical record. Record review showed that Resident #123 was admitted on an unspecified date and discharged on 11/07/2025, but the medical record contained no documentation of a completed discharge summary. During a record review and interview on 01/28/2026 at 2:06 p.m., the Social Services Director confirmed that the resident had been discharged on 11/07/2025 and further confirmed that a discharge summary was not completed for this resident. No additional medical history or condition details for the resident at the time of discharge were documented in the report.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure an allegation of physical abuse was reported immediately, and no later than two hours after the allegation, to the State Survey Agency for two residents involved in resident-to-resident abuse. The facility policy titled, Abuse Investigation and Reporting, stated that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property, are to be reported immediately, but no later than two hours if the allegation involves abuse or serious bodily injury. Resident #2 had diagnoses including Alzheimer's disease, dementia with other behavioral disturbances, major depressive disorder, and anxiety disorder, and her BIMS score was 08, indicating moderate cognitive impairment. Resident #81 had diagnoses including bipolar disorder and depression with psychotic features, and her BIMS score was 14, indicating she was cognitively intact. On 12/06/2025, Resident #2 was in the hallway in her wheelchair when Resident #81 confronted her about allegedly stealing soda, and Resident #2 struck Resident #81 on the leg while staff separated them. On 12/07/2025, Resident #2 was again in the hallway when Resident #81 came out of her room and kicked Resident #2 on the leg; Resident #81 admitted she kicked Resident #2 because Resident #2 had hit her the day before and stolen her pop. Staff interviews confirmed the administrator was notified of both incidents when they occurred, but the administrator stated the incidents were not reported to the state agency.
Failure to Provide Needed Grooming and Nail Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received the necessary services to maintain good grooming and personal hygiene. The cited policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene, and that if a resident with cognitive impairment or dementia resisted care, staff should attempt to identify the underlying cause rather than assume refusal. Resident #9 was admitted with diagnoses including unspecified dementia, psychotic disturbance, mood disturbance, anxiety, and encounter for attention to gastrostomy. The resident's MDS indicated the resident did not exhibit rejection of care and was dependent for personal hygiene. The care plan identified a self-care deficit with assistance needed for ADLs and personal hygiene as totally dependent. During observation, the resident was found in bed with the left hand exposed and the fingernails on the left hand were long and dirty with a thick brown substance under the left middle fingernail. The same condition was observed again the next day. During the final observation, the Assistant DON/Infection Preventionist confirmed the findings and stated the CNA should have cleaned the resident's nails or notified the treatment nurse if unable to do so; the treatment nurse stated she had not been notified that the resident refused nail care.
Failure to Document and Investigate Resident Complaints
Penalty
Summary
The facility failed to document, investigate, and maintain records of complaints voiced during resident council meetings held in July and October 2024. The facility's policy requires that upon receipt of a grievance or complaint, the designee must review and investigate the allegations and submit a written report of the findings to the administrator within five working days. However, during interviews with residents and staff, it was revealed that complaints about the inconsistency of ice being passed to residents were not documented or investigated as grievances. The Activity Director admitted to not writing up the complaints because only one resident complained in each meeting, and instead, she provided ice and water to the resident and informed the CNA supervisor. Residents expressed dissatisfaction with the inconsistency of ice distribution, stating that while the issue would be temporarily resolved after being reported, it would soon revert to the previous state of neglect. One resident mentioned that having a schedule for ice and water distribution would prevent them from feeling like they were bothering staff. The CNA Supervisor could not recall any complaints about the issue and confirmed there was no documentation of such complaints. This lack of documentation and investigation of grievances is a deficiency in honoring residents' rights to voice concerns and have them addressed appropriately.
Failure to Notify Physician and Document Choking Incident in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. For one resident with end-stage heart failure, unspecified dementia, and type 2 diabetes mellitus, the facility did not notify the physician of abnormal capillary blood glucose (CBG) levels as ordered. The resident's medical records showed multiple instances of CBG levels exceeding 401, which required immediate notification to the physician according to the facility's policy. However, there was no documentation indicating that the physician was informed of these abnormal results, as confirmed by the Corporate Nurse during an interview. Another resident, who was cognitively intact and had diagnoses including paraplegia and gastroesophageal reflux disease, experienced a choking incident. The resident choked on food and was subsequently transferred to the emergency room for evaluation due to esophageal obstruction. Despite this significant event, the resident's comprehensive care plan did not include a focus area or interventions related to the choking incident. Both the Minimum Data Set Coordinator and the Director of Nursing confirmed that the incident should have been documented in the care plan with appropriate interventions, but it was not.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that recipes for pureed diets were followed, which had the potential to negatively impact the dining experience and nutritional intake of 12 residents receiving pureed meals. Observations revealed that S4Cook prepared pureed rice without measuring the water or rice, relying on guesswork to achieve the desired consistency. Similarly, S5Cook prepared pureed bread and beans that resulted in a thin liquid consistency, which was not appropriate for a pureed diet. Both cooks demonstrated a lack of adherence to the facility's puree recipe guidelines. Interviews with dietary staff, including S6DS, S8Cook, and S9DS, revealed a lack of training on how to properly puree foods using recipes. S6DS confirmed that the puree recipe liquid addition quick guide was not helpful, as it lacked specific measurements for certain foods. Additionally, S7RD, the registered dietician, confirmed that puree recipes were not available in the main kitchen for cooks to reference. This lack of training and resources contributed to the improper preparation of pureed meals, potentially affecting the nutritional needs of the residents.
Deficiencies in Hospice Care Coordination and Communication
Penalty
Summary
The facility failed to provide services that met professional standards for two residents receiving hospice care. For one resident, the facility did not collaborate effectively with the hospice agency to ensure that the hospice nurse's visit notes and certification were up-to-date in the resident's hospice binder. The last certification period was noted to be outdated, and the last hospice nurse visit notes were several months old. During interviews, facility staff were unclear about who was responsible for ensuring the hospice binder was updated, with the Director of Nursing indicating that it was the hospice agency's responsibility. For the second resident, the facility failed to communicate with the hospice agency regarding the resident's high blood sugar levels. The resident had multiple occurrences of critically high blood glucose levels over several months, yet there was no documentation indicating that the hospice agency was informed of these abnormal levels. The Corporate Nurse confirmed the lack of communication, and the Hospice Agency Director of Nursing stated that the hospice should have been notified of such significant changes in the resident's condition.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medication, as required by their policy. The policy mandates that residents can self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe. However, there was no assessment, physician's order, or care plan for the resident to self-administer medication. The resident, who had a diagnosis of Gastro-Esophageal Reflux Disease and a BIMS score indicating moderate cognitive impairment, was observed with a medicine cup containing medication on her bedside table, which she intended to take herself. An LPN confirmed that she had left the medication, identified as Mylanta, on the resident's bedside table, acknowledging that the resident preferred to take it in intervals. The Director of Nursing confirmed that the resident's record lacked the necessary documentation to support self-administration of medication, and it was inappropriate for the medication to be left at the bedside. This oversight indicates a failure to adhere to the facility's policy on self-administration of medications, compromising the safety and care of the resident.
Failure to Report Injuries of Unknown Source
Penalty
Summary
The facility failed to report alleged injuries of unknown source to the State Survey Agency within the required two-hour timeframe for two residents. Resident #84, who has severe cognitive impairment, was found on the floor outside her room with a fracture to her left arm and was diagnosed with a urinary tract infection. The incident was not reported to the state agency as required by the facility's policy. Similarly, Resident #113, also with severe cognitive impairment, was found sitting on the floor with a head bruise and a fracture to his left wrist. This incident was also not reported to the state agency. Both residents were unable to recall the events leading to their injuries, and the Director of Nursing confirmed that these incidents should have been reported but were not.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman of facility-initiated transfers for two residents, which is a requirement for ensuring proper oversight and resident rights. Resident #84, who had diagnoses including Alzheimer's disease, major depressive disorder, and anxiety disorder, was transferred to the hospital on multiple occasions, specifically on 10/15/2024, 11/08/2024, and 11/17/2024. However, these transfers were not recorded in the Emergency Transfer Log for October and November 2024, which is used to notify the Ombudsman. Similarly, Resident #113, with diagnoses including dementia, depression, and repeated falls, was transferred to the hospital on several dates, including 08/19/2024, 10/10/2024, 10/12/2024, 11/28/2024, and 12/02/2024, but these were also not documented in the Emergency Transfer Log. The Business Office Manager (BOM), responsible for maintaining the Emergency Transfer Log and notifying the Ombudsman, confirmed the omissions during an interview and record review. The BOM was unaware that facility-initiated transfers, even those lasting less than 24 hours, needed to be included in the log sent to the Ombudsman. This oversight in documentation and notification could potentially affect the facility's entire census of 112 residents, as it undermines the regulatory requirement to inform the Ombudsman of all facility-initiated transfers.
Failure to Administer Enteral Feeding at Ordered Rate
Penalty
Summary
The facility failed to ensure that the enteral feeding for a resident was infused at the ordered rate, which was a deficiency identified during a survey. The facility's policy on enteral feedings required checking the rate of administration against the order before administration. However, an observation and interview with an LPN revealed that the enteral feeding for a resident with Alzheimer's disease, unspecified dementia, dysphagia, chronic systolic heart failure, and a gastrostomy was running at 45 ml/hour, contrary to the ordered rate of 44 ml/hour. This discrepancy was confirmed by the LPN, indicating a failure to adhere to the prescribed feeding rate, which had the potential to affect other residents receiving tube feedings in the facility.
Inaccurate Documentation of Care Plan for Resident
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards and practices by not ensuring that the comprehensive care plan for a resident was accurately documented. The resident in question was admitted with diagnoses including paraplegia, spinal stenosis, muscle wasting and atrophy, and ileus. A review of the resident's progress notes revealed significant weight loss over several months, with a current weight of 121.2 pounds and a BMI of 18.4, indicating an underweight status. The resident's weight loss was documented with specific percentage changes compared to previous weights, triggering a need for weekly weight monitoring until stabilization. However, the comprehensive care plan for the resident only included an intervention to weigh the resident monthly, which was inconsistent with the need for weekly monitoring as indicated by the progress notes. This discrepancy was confirmed during a record review and interview with the Minimum Data Set Coordinator/LPN, who acknowledged that the care plan did not accurately reflect the required frequency of weight monitoring. This failure to document the necessary intervention in the care plan represents a deficiency in maintaining accurate medical records, potentially affecting the facility's entire census of 112 residents.
Inadequate Use of PPE During Biohazard Trash Removal
Penalty
Summary
The facility failed to maintain an effective infection control and prevention program by not ensuring staff used personal protective equipment (PPE) according to accepted standards during biohazard trash removal. During an observation on Hall A, a treatment cart was found with a trash can attached, containing a red biohazard trash bag. A partially discarded blue glove was observed hanging halfway out of the bag. The Treatment Nurse, after completing her treatments, was seen removing the glove and the biohazard bag without wearing gloves, and then placing the biohazard bag on top of the treatment cart. The Director of Nursing, who also serves as the facility's Infection Preventionist, confirmed that the Treatment Nurse should have donned gloves before handling the soiled glove and biohazard materials. Additionally, the biohazard bag should not have been placed on top of the treatment cart. This incident highlights a lapse in following the facility's policy on the use of gloves to prevent the spread of infection and protect staff from potentially infectious materials.
Failure to Monitor and Report Wound Deterioration
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not have a registered nurse monitor weekly body/skin assessments and wound care evaluations, which were performed only by Licensed Practical Nurses (LPNs) for ten sampled residents with wounds. This oversight led to an Immediate Jeopardy situation when the facility failed to notify the physician of a deteriorating right foot wound and did not identify and report a new wound on the left foot of Resident #2, resulting in an infestation of maggots in both feet. Resident #2 was admitted to the facility with multiple diagnoses, including Hemiplegia, Schizoaffective Disorder, Peripheral Vascular Disease, and Type 2 Diabetes Mellitus, among others. The resident's comprehensive care plan noted a potential for skin breakdown due to decreased mobility and other factors. Despite having a physician's order for daily wound care on the right foot, the wound evaluations showed significant deterioration from early April to late April, with no documentation of notification to the physician or nurse practitioner. Additionally, body audit/skin assessments failed to identify a new wound on the left foot, which was later discovered to be infested with maggots. Interviews with facility staff revealed that the LPNs were responsible for conducting body audit/skin assessments and reporting any changes to the wound care nurse, who was also an LPN. However, there was no oversight by a registered nurse, and the wound care nurse did not assess the left foot or lower extremity as she was only responsible for active wounds. The Director of Nursing confirmed that the assessments were not conducted properly, and there was a lack of documentation regarding changes in the resident's condition. This failure to monitor and report changes in the resident's wounds led to severe consequences for Resident #2.
Lack of RN Oversight in Wound Care Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to administer an effective wound prevention program with appropriate professional oversight, leading to a deficiency in the care provided to residents. Specifically, the facility did not ensure that Registered Nurses (RNs) monitored weekly body/skin assessments and wound evaluations performed by Licensed Practical Nurses (LPNs) for ten sampled residents. This lack of oversight had the potential to cause severe harm, injury, or death to 117 residents who received weekly unmonitored body/skin assessments and wound care. The deficiency was highlighted by an Immediate Jeopardy situation when the facility failed to notify a physician of a deteriorating right foot wound and did not identify and report a new wound on a resident's left foot, resulting in an infestation of maggots on both feet. Interviews and record reviews revealed that the facility's LPNs were responsible for conducting all residents' body audits/skin assessments and wound evaluations without RN oversight. The Director of Nursing (DON) confirmed that neither she nor the Assistant Director of Nursing reviewed these assessments. Additionally, the data entry clerk, an LPN, was responsible for ensuring that all assessments and evaluations were documented in the residents' charts. The Corporate Nurse was aware that weekly skin and wound evaluations were conducted by LPNs without RN monitoring, which contributed to the deficiency.
Failure to Notify of Worsening Wound Condition
Penalty
Summary
The facility failed to notify the responsible party, nurse practitioner, and physician of a resident's deteriorating right foot wound in a timely manner. The resident, who was admitted with multiple diagnoses including hemiplegia, schizoaffective disorder, and peripheral vascular disease, had a wound on the right dorsum foot that significantly increased in size over several weeks. Despite the wound's worsening condition, there was no documentation of notification to the resident's responsible party or healthcare providers. Interviews revealed that the resident's responsible party was unaware of the wound's deterioration, and the nurse practitioner was not informed of the worsening condition. The wound care nurse acknowledged the wound's increasing maceration and drainage but confirmed that no notification was made to the responsible party. The facility's policy on wound prevention did not specify which professional discipline should perform assessments or to whom changes should be reported, contributing to the communication breakdown.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 126 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Abbeville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastridge Nursing & Rehabilitation | 1.1 mi | ★★★★★ | 6 | 0 |
| Vermilion Health Care Center | 7.4 mi | ★★★★★ | 0 | 0 |
| Pelican Pointe Healthcare And Rehabilitation | 9 mi | ★★★★★ | 2 | 0 |
| Kaplan Healthcare Center | 12.4 mi | ★★★★★ | 14 | 0 |
| Maison De Lafayette | 12.7 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Maison Du Monde Living Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.