Norton Community Hospital SNF Unit

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to offer a 2025-2026 COVID-19 vaccine for three (3) of eight (8) sampled residents (Resident #5, Resident #13, and Resident #12). Resident #5 developed COVID-19 26 days following admission thus resulting in harm for Resident #5. The facility staff also failed to offer 2025-2026 COVID-19 vaccines to the facility staff.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to conduct an admission minimum data set (MDS) assessment within 14 calendar days after admission for two (2) of eight (8) sampled residents (Resident #1 and Resident #5).

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to electronically transmit an admission minimum data set (MDS) assessment within 14 days following completion for one (1) of eight (8) sampled residents (Resident #1).

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the drug regimen review of each resident was reviewed at least monthly by a licensed pharmacist for one (1) of eight (8) sampled residents (Resident #1).

Inspectors wroteBased on observation and facility document review, the facility staff failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of infections as evidenced by failure to use appropriate hand hygiene during medication administration.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for two (2) of eight (8) sampled residents (Resident #1 and Resident #12).

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to ensure the sanitizing solution was maintained at an acceptable level to sanitize food contact surfaces; and failed to perform hand hygiene after contaminating their gloves and before touching resident food. This had the potential to affect 25 of 25 residents residing in the facility.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure Resident (R)23's assessment accurately reflected gradual dose reduction attempts for an antipsychotic. This failure affected one of five residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, record review and facility policy/procedure review the facility failed to ensure a resident's Port-A-Cath (also known as an intravenous vascular access port -IVAP) was flushed with heparin by a Registered Nurse (RN) and not by a Licensed Practical Nurse (LPN). Per accepted standards of practice, these flushes are outside an LPN's scope of practice. The deficient practice affected one sampled resident (R)21 and one unsampled resident R22; and had the potential for poor quality of care for all residents, if staff operated outside their accepted scope of practice.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the correct physician's order was followed for wound care for one of 12 sampled residents (Resident (R)11). The failure to follow current physician's orders for wound care could impede healing of the sacral pressure ulcer being treated, and increase the health risks associated with a wound, such as infection and sepsis.

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents who received antipsychotic medications had a gradual dose reduction attempt at least annually. This failure affected 1 resident (R)esident 23) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and facility policy review the facility failed to ensure expired medications were removed from the medication cart and the medication storage room. This deficient practice occurred in one of one med rooms and two of two med carts; and could potentially lead to administering ineffective, outdated medications to the residents.

Inspectors wroteBased on observation, menu review, and staff interview the facility failed to follow the menu selected for the residents. This affected three (Resident (R) 2, R20, R23) of 25 residents in the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure the scissors, used by the nurse, to cut dressings for a pressure ulcer were cleaned prior to use on the dressing for one of 12 sampled residents (Resident (R) 11). The failure to follow accepted standards of practice related to infection control with wound care could potentially introduce bacteria into the wound causing an infection.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to protect the private health care information for 1 of 15 Residents, Resident #192.

Inspectors wroteBased on staff interview, clinical record review, and facility document review the facility staff failed to follow professional standards of practice for 1 of 15 Residents, Resident #12.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to coordinate care with dialysis center for 1 of 15 Residents, Resident #41.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure one of 15 Residents were free from unnecessary medications, Resident #30.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure two of 15 Residents, were free of significant medication errors, Residents #14 and #30.

Inspectors wrote2. The facility staff failed to ensure the medication cart was locked when unattended. On 09/05/18 at approximately 8:19 a.m., surveyor #1 observed RN ( registered nurse) #1 during a medication administration observation. During this observation RN #1 was observed preparing and administering medications. After preparing the medications RN #1 entered a Resident's rooms to administer the medications leaving medication draw open and medication cart unlocked in hallway. The medication cart was out of RN#1's view. Surveyor #2 observed housekeeping personnel, dietary personnel and one resident in the hallway during this observation. After the medication administration surveyor #1 approached RN #1 and interviewed her regarding the medication cart being open. RN #1 verbalized to the surveyor that she leaves the cart open if it is facing the room. [...]

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure an effective infection control program for one of 15 Residents, Resident #194.