Norwich Springs Health Campus

Inspectors wroteBased on closed medical record review and staff interview, the facility failed to ensure timely coordination of outside medial appointments. This affected one (#77) of three residents reviewed for medical appointment follow-up. The facility census was 50.

Inspectors wroteBased on observation, resident interview, staff interview, and policy review the facility failed to ensure infection control procedures were followed for laundry which had the potential to affect all 52 residents residing in the facility. Additionally, the facility failed to ensure infection control was followed for wound care for one (Resident #12) out of three residents reviewed for pressure ulcers. Lastly, the facility failed to follow infection control procedure for indwelling urinary catheter care for one (Resident #02) out of one resident reviewed for catheter care. The facility census was 52.1. Interview on 03/25/26 from 8:10 A.M. to 8:20 A.M. [...]

Inspectors wroteBased on review of resident record, observations and staff interviews, the facility failed to ensure dignity for a resident. This affected one resident (Resident #58) of three residents reviewed for dignity. The facility census was 52 residents.

Inspectors wroteBased on review of medical records, staff interview, and facility policy review, the facility failed to follow care instructions for nephrostomy care for Resident #02. This affected one resident (Resident #02) of three residents investigated for urinary catheters. The facility census was 52.

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to ensure a specialist appointment was scheduled for one (Resident #12) out two residents reviewed for activities of daily living. The facility census was 52. Review of the medical record for Resident #12 revealed an admission date of 12/22/2023. Diagnoses included but not limited to polyneuropathy, contracture of right knee, contracture of left knee, and contracture of muscle of left upper arm. Review of the annual Minimum Data Set (MDS) 3.0 assessment for Resident #12, dated 01/11/2026, revealed a Brief Interview for Mental Status score of 12, indicating the resident was cognitively intact. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide oxygen therapy services per physician's order for Resident #52 and Resident #33, the facility also failed to ensure the nasal cannula was kept in sanitary condition for Resident #33. This affected two Residents (#52 and #33) of four reviewed for respiratory services. It had the potential to affect 10 residents the facility identified as using oxygen therapy in their plan of care. The facility census was 52.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure antibiotic stewardship was followed for two (Residents #11 and #12) out of four residents reviewed for antibiotic stewardship. The facility census was 52. 1. Review of the medical record for Resident #11 revealed an admission date of 02/04/26. Diagnoses included dementia, pulmonary fibrosis, anxiety, and pleural effusion. Review of the five-day Minimum Data Set (MDS) 3.0 assessment for Resident #11, dated 02/10/26, revealed a Brief Interview for Mental Status score of 10, indicating the resident had moderate cognitive impairment. Review of physician orders for Resident #11 revealed an order dated 03/09/26 for Levofloxacin (antibiotic) 500 milligrams by mouth once daily for a urinary tract infection through 03/11/26. [...]

Inspectors wroteBased on observation, record review, staff interview, review of protective cream labels, and review of facility policy, the facility failed to ensure a Stage 3 pressure ulcer present upon admission received treatment and failed to ensure proper linens were used with a pressure reducing mattress to promote healing of the pressure ulcer for one (Resident #3) of three residents reviewed for pressure ulcers. The facility census was 52.

Inspectors wroteBased on record review, interview and policy review, the facility failed to maintain a water management plan that included monitoring measures and acceptable ranges and failed to identify the presence of abnormal test results and take appropriate action. This had potential to affect all facility residents. The facility census was 39.

Inspectors wrote6. Record review for Resident #3 revealed an admission date of 03/23/23. Diagnoses included chronic respiratory failure, major depression, altered mental status, dysphagia, cognitive communication deficit. Review of the MDS assessment dated [DATE] revealed Resident #3 was cognitively impaired. Resident #3 had a physician order dated 03/19/24 to take out hearing aides every evening and an order dated 05/09/24 to place hearing aides in ear every morning. Resident had one for both ears and informed staff to listen for a whistle and if a whistle was not heard to change the battery. Review of the care plan revealed the resident had hearing loss. Hearing aides were not included on the care plan and no interventions on monitoring hearing loss and hearing aides was available. During an interview on 05/30/24 at 10:38 A.M., Resident #3's representative stated the resident wore hearing aides. [...]

Inspectors wroteBased on record review, interview, and policy review the facility failed to assess and/or obtain consents or orders for the use of bed rails. This affected six (Residents #27, #34, #36, #190, #194, and #196) of six reviewed for bed rails. The facility identified 29 residents who use side rails. The facility census was 39.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure medications were not left at the bedside. This affected one (Resident #30). The facility identified four mobile cognitively impaired residents (#3, #26, #28, and #248) in the facility. The facility census was 39.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure signed consents were completed and vaccinations were administered timely for pneumonia and flu vaccines. This affected three (Residents #14, #25, and #28) of five residents revealed for vaccinations. Facility census was 39.

Inspectors wroteBased on record review, interview, and policy review the facility failed to address bed rails on the baseline care plan. This affected one (Resident #196) of three residents reviewed for baseline care plans. The facility census was 39.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident was assessed prior to removal of a Wanderguard bracelet. This affected one (Resident 321) of two residents reviewed for wandering and elopement. The facility census was 39.

Inspectors wroteBased on record review, observations and interview the facility failed to ensure a the correct catheter bag was used to prevent urine reflux into Resident #28 bladder. This affected one (Resident #28) of three residents reviewed for urinary catheters. The facility census was 39.

Inspectors wroteBased on record review, observation, interview and manufacturer's instruction review, the facility failed to prime an insulin pen prior to administration, resulting in a signficant medication error. This affected one (Resident #23) of five residents observed during medication pass. The facility census was 39.

Inspectors wroteBased on record review, observations, resident and staff interviews, and policy review, the facility failed to provide residents with assistance with activities of daily living (ADL) including oral care and/or bathing services. This affected two (#30 and #35) out of six residents reviewed for ADL/personal hygiene. Facility census was 42.

Inspectors wroteBased on medical record review, observations and staff interviews, the facility failed to provide a resident with medication as ordered by the physician which resulted in a significant medication error when the resident was provided a medication he was not ordered and the medication was listed as a mediation the resident was allergic to. This affected one (#45) out of two residents observed for medication administration. Facility census was 42.