Norwich Rehabilitation & Nursing Center

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00353879) surveys conducted 7/29/2025-8/1/2025, the facility did not ensure a safe, comfortable, and homelike environment for two (2) of two (2) residents (Residents #39 and #80) reviewed and seven (7) anonymous residents present at the group meeting. Specifically, Resident #39's room and bathroom had a strong odor of urine; Resident #80 had missing clothing items and a wheelchair with a wheel in disrepair; and seven (7) anonymous residents reported they had items missing from laundry.

Inspectors wroteBased on interview and record review during the recertification survey conducted 7/29/2025-8/1/2025 the facility did not develop and implement an effective discharge planning process that focused on the resident's discharge goals for two (2) of three (3) residents (Resident #1 and Resident #90). Specifically, there was no documented evidence of an ongoing discharge plan for Resident #1 and Resident #90.

Inspectors wroteBased on observations, interviews, and record review during the recertification survey conducted 7/29/2025-8/1/2025, the facility did not develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for one (1) of one (1) resident (Resident #1) reviewed. Specifically, Resident #1 did not have a care plan for managing anticoagulant therapy (blood thinner).

Inspectors wroteBased on observations, record review, and interview during the recertification survey conducted 7/29/20225-8/1/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for one (1) of four (4) residents (Resident #3) reviewed. Specifically, Resident #3 had a significant weight loss, weekly weights were not completed as ordered, the medical providers were not notified of the weight loss and the resident had a functional decline in their eating ability and a referral for an occupational therapy evaluation was not submitted timely.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 7/29/2025-8/1/2025, the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 was observed with a continuous positive airway pressure machine, and the medical record did not include a physician order or a care plan related to the use of the continuous positive airway pressure machine.

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure the provision of food and drink was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 meal trays tested. Specifically, food was not served at palatable and safe temperatures.

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00361060), the facility failed to establish mechanisms for documenting and communicating the resident's choice regarding Advance Directives to the staff responsible for the resident's care for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 updated their Medical Orders for Life-Sustaining Treatment to reflect a change from wanting cardiopulmonary resuscitation (attempt to restart the heart) to do not resuscitate (allow natural death). The medical record and code status indicators were not revised to reflect the resident's Advance Directives wishes and the facility continued with cardiopulmonary resuscitation orders. [...]

Inspectors wroteBased on record review, observation, and interview during the recertification survey conducted 1/3/2024-1/9/2024, the facility did not ensure storage and preparation of food in accordance with professional standards for food service safety for 3 of 3 kitchens (the main kitchen and Units 2 and 3 kitchenettes) reviewed. Specifically, the main kitchen had expired sanitizer strips for the three-bay sink; fruit flies were observed in the main kitchen and the Unit 2 and Unit 3 kitchenettes; the ice machines in the Unit 2 and 3 kitchenettes were damaged; the Unit 3 kitchenette had an undated open loaf of bread; and the Unit 2 kitchenette walls and ceiling were unclean.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00325041) surveys conducted 1/3/2024-1/9/2024, the facility did not ensure allegations of abuse, neglect, or mistreatment were thoroughly investigated to prevent further potential abuse for 2 of 2 residents (Residents #62 and #235) reviewed. Specifically, Resident #235 reported they were slapped in the face by Resident #62, the incident was not thoroughly investigated and was not reported to the New York State Department of Health as required.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00327028) surveys conducted 1/3/2024-1/9/2023, the facility did not ensure each resident received adequate supervision and assistive devices for 1 of 4 residents (Resident #232) reviewed. Specifically, Resident #232 was care planned for a wander alert device to be worn at all times, the device was removed when the resident was sent to the hospital, the device was not reapplied when they returned to the facility, and the resident was not supervised until the device was replaced. Subsequently, Resident #232 was observed alone in a non-residential area.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 1/3/2024 -1/9/2024, the facility did not ensure that residents who required dialysis services received such services consistent with professional standards of practice for 1 of 1 resident (Resident #335) reviewed. Specifically, Resident #335 received hemodialysis (a process of purifying blood when the kidneys do not work properly) treatments at a community-based dialysis center and did not have on-going assessment and oversight before and after dialysis treatments including assessment of the dialysis access site; did not have a comprehensive care plan that addressed dialysis; and there was not consistent ongoing communication and collaboration between the facility and the dialysis center.

Inspectors wroteBased on observation and interview during the recertification survey conducted 7/6/21-7/9/21, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents (Residents # 4, 15, 45 and 78) observed during medication administration. Specifically, licensed practical nurse (LPN) #10 was observed not performing hand hygiene between consecutive medication administrations for Residents #4, 15, 78 and 79. Findings Include: The facility policy Administration of Medication updated 3/1/20 documented that medications are administered in a safe and timely manner, and as prescribed. [...]