Norwood Crossing

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement and maintain an effective infection prevention and control program to prevent the transmission of communicable disease. The facility failed to ensure staff used appropriate personal protective equipment (PPE) when entering residents' contact isolation room, failed to properly handle and store contaminated linen and clothing, failed to follow facility protocol for laundering linens belonging to a resident diagnosed with crusted scabies, and failed to maintain required contact isolation by allowing the resident to leave the isolation room. These deficient practices affected two (R1, R3) out of five residents reviewed for infection prevention and had the potential to affect all 101 residents residing in the facility. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy to provide medical records within 30 days of the request for one resident (R2) out of four residents reviewed for resident rights. Findings Include: [...]

Inspectors wroteBased on interviews and record review, facility failed to ensure that one resident (R4) is free from verbal abuse from a staff member. These failures affected one resident (R4) out of three residents reviewed for abuse.

Inspectors wroteBased on interviews and record review, facility failed to timely report verbal abuse incident to the state agency within 2 hours and failed to follow facility's abuse and abuse reporting policy for one resident (R4) in the sample of three residents reviewed for physical and verbal abuse/assault.

Inspectors wroteBased on interviews and records reviewed the facility failed to ensure one resident (R1) remained free from verbal and physical sexual abuse from a resident (R2) who had a history of inappropriate sexual behavior with another resident (R3) prior. This failure affected three of three residents reviewed for abuse on the sample list of five.

Inspectors wroteBased on interviews and records reviewed the facility failed to report an allegation of abuse to the state agency. This failure affects two of three residents (R2/R3) reviewed for abuse in the sample of five.

Inspectors wroteBased on interviews and records reviewed the facility failed to investigate an allegation of abuse for one resident (R3). This failure affects two of three residents (R2/R3) reviewed for abuse on the sample list of five.

Inspectors wroteBased on interview and record review, the facility failed to supervise one resident (R1) who was a high risk for falls. This failure resulted in R1 falling to the floor and sustaining a broken clavicle. This failure affected one of three residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to have an effective pest control program by having gnats flying around residents room and kitchen area. This failure has the potential to affect all 107 of the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) provide adequate supervision and monitoring for fall risk residents and b.) follow their policy to ensure accident prevention measures were in place by not ensuring a dependable locking mechanism on a soiled utility room door. These failures affect R22, R34, R55, R60, R63, R67 and all residents residing on the second floor.

Inspectors wroteBased on observation, interview and record review, facility failed to provide medication in compliance with standards of professional practice for five residents (R19, R32, R39, R58, R77) out of 7 residents reviewed for medication administration in a sample of 24 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of practice by failing to label medications when opened; and (b) failing to label medications with an expiration date an (c) dispose of expired medical supplies. This failure affects residents receiving medications from the second and third floor medication cart. Finding Include: On [DATE] at 10:43 AM, during a certification and licensure survey, the surveyor audited the 2nd floor odd side Medication Cart with V26 (registered nurse). The surveyor found: a bottle of R17's Humalog insulin vial with an open date of [DATE] and no marked date when the medication expires; a bottle of Gas Relief (Simethicone) 100 chewable tablets with no marked date when the medication was opened and no marked date of when the medication expires; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice infection control and prevention and ensure the appropriate personal protective equipment (PPE) was worn by staff caring for a resident on enhanced barrier precautions. This failure affects one (R6) reviewed for infection control on the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ADL (Activities of Daily Living) care was provided for dependent residents who required assistance with bladder and bowel incontinence for one of one resident (R56) reviewed for ADL care in the sample of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide 1:1 feeding assistance in a timely manner for one (R2) resident out of seven residents in a total sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a pressure relieving device was functioning properly for one (R20) who is at risk for pressure ulcers out of seven residents in a total sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were not left at bedside for one (R2) resident and failed to ensure a treatment cart was locked when not in visual proximity of the nurse and not in use. This failure has the potential to affect all 36-residents residing on the 4th floor of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly log refrigerator and freezer temperatures in the facility kitchen; and failed to properly log the checking of the dating and labeling of food items and removal of expired items in the facility kitchen. These failures have the potential to affect all 104 residents receiving an oral diet in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that one resident (R1) was treated in a dignified manner. This failure affected one resident (R1) out of four residents reviewed for dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one resident (R1) with a venous stasis ulcer received the necessary treatment and services to promote wound healing. This failure affected one resident (R1) out of four residents reviewed for wound care.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide adequate supervision for one resident [R5] who is a high fall risk out of three residents reviewed for falls. This failure resulted in R5 experiencing an unwitnessed fall and sustaining an acute nondisplaced fracture of the L5 superior endplate with extension to the left L5 transverse process (Lumbar Fracture). Findings Include, R5 clinical record indicate in part; [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to obtain monthly weights and recognize, evaluate, and address weight loss for three (R17, R66, and R61) residents out of a total sample of 22 residents. This failure resulted in R17 having a 15.7 percent decrease in weight in six months between 12/4/2023 (121 pounds) and 6/4/2024 (102 pounds).

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to label, and date stored food, failed to discard expired food, and failed to store food items separate from cleaning products. These failures have the potential to affect 106 residents in the facility who is receiving an oral diet. The facility's Tally sheet documents 109 residents in the facility with 3 being NPO [nothing by mouth].

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain enhanced barrier precautions for three residents (R28, R64, R78), failed to educate visitors on contract isolation precautions for one resident (R166), failed to maintain suction equipment within professional standards of practice for one resident (R78) and failed to annually update policies relative to infection prevention and control. This failure has the potential to affect the entire facility census of one hundred and nine residents. Findings Include: On 6/11/2024 at 2:34 PM R78 had an EBP (enhanced barrier precautions) sign on the door. V10 (Registered Nurse) entered R78's room without performing hand hygiene and touched R78's suction equipment. On 6/11/2024 at 2:42 PM R78 had an EBP (enhanced barrier precautions) sign on the door. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy and procedure to ensure proper linens were used on the low air loss mattress for 2 residents (R1, R63) and to ensure low air loss mattress devices were functioning and on the correct settings for 2 (R61, R90) out of 4 dependent residents who are at risk in developing pressure ulcer in a final sample of 22 residents. Findings Include: 1. On 6/11/24 at 11:05 AM, R61 was sleeping in bed and noted low air loss mattress weight control knob was set between 287 and 375 pounds. R61's clinical records show R61 has diagnoses not limited to Alzheimer's Disease and Type 2 Diabetes Mellitus. R61's Minimum Data Set (MDS) dated [DATE] shows R61 is cognitively impaired and is dependent on staff for turning and repositioning in bed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure (R54) residents' oxygen was on the correct setting as ordered by the physician, ensure (R4) residents' oxygen tubing was connected and functioning properly, ensure (R41, R54, R60) residents oxygen supplies were labeled and dated per the facilities policy and ensure (R41, R60, R70) residents respiratory supplies were stored to prevent contamination in a sample of 22. Findings Include: R4 has diagnosis not limited to Heart Failure, Depressive Episodes, Mild Cognitive Impairment, Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease, Personal History of Transient Ischemic Attack and Need for Assistance with Personal Care. Care Plan document in part: R4 has COPD (Chronic Obstructive Pulmonary Disease). The resident will display optimal breathing pattern daily through review date. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to label a personal use medication (R8), discard medications past the 'Best By date,' discard open medications not in their original packaging and return discontinued medications (R15). This has the potential to affect R8 and all residents that receive medications from the fourth floor, odd side, medication cart.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was self-administering medications had a self-administration of medications assessment, a physician's order, and a care plan completed for 1 (R54) resident reviewed for self-administration of medications in a sample of 22. Findings Include: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the provider order and care plan reflected the resident's wishes on the Provider Order for Life-Sustaining Treatment (POLST) form for one residents (R78) out of twenty-two total residents in the sample.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow physician orders and update a resident's (R14) care plan for one resident out of a total sample of 22 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to apply splint and complete quarterly restorative assessments that detail the progress or lack of progress in the restorative services for 1 (R61) out of 1 resident reviewed for limited range of motion and restorative services in the final sample of 22. Findings Include: On 6/11/24 at 11:07 AM, R61 was sleeping in bed. Surveyor noted R61 has both hands contractures, and no assistive devices/splints were in place. On 6/12/24 at 2:23 PM, interviewed V22 (Wound Care Nurse/Restorative Nurse Supervisor) and stated that R61 is on active and passive range of motion restorative programs. V22 stated that R61 is supposed to have a splint for the contracted hand. V22 stated, I forgot which hand. [R61] should always have it every day except during incontinence care or when bathing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items were properly labeled, dated, and stored and failed to store equipment in separate area from bulk food bins. This deficient practice has the potential to affect all 112 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dependent residents requiring 1:1 feeding were treated with respect and dignity by not being fed simultaneously with the other residents. These failures affected 4 residents (R8, R42, R78, R96) reviewed during dining observations in a total sample of 23 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure shared equipment was cleaned and decontaminated between each use for four [R28, R65, R81, R105] of seven residents reviewed for medication administration observation on the total sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the call light was within reach for 1 (R65) of 23 residents reviewed for call lights on the total sample of 23. Findings Include: R65 has diagnosis not limited to Metabolic Encephalopathy, Type 2 Diabetes Mellitus with Unspecified Complications, Acute Kidney Failure, Dementia, Muscle Weakness, Difficulty in Walking and Need for Assistance with Personal Care. Care Plan document in part: R65 is at risk for falls d/t (Due/to) impaired mobility, Gait/balance problems, Dementia, and incontinence. Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 08/08/23 at 11:20 AM R65 was lying in bed on a low air loss mattress. R65 call light was wrapped around and hanging from the left upper side rail touching the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an air mattress used for pressure reduction was on and operating while the resident was in bed, for one (R23) of four residents reviewed for wound prevention in a sample of 23. Findings Include: R23 has diagnosis not limited to Fracture of Superior Rim of Right Pubis, Chronic Obstructive pulmonary Disease, Major Depressive Disorder and Dementia. Care Plan document in part R23 is at risk for pressure ulcer/skin breakdown d/t (Due/to) impaired mobility, right pelvic fracture, and incontinence. Intervention: Air mattress in place. Order Summary report dated 08/09/23 document in part: Air mattress. On 08/08/23 at 10:33 AM R23 was lying in bed asleep on a low air loss mattress the was not on and operating. R23 was sunken in the middle of the air mattress. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy by not administering oxygen per physician's orders and not storing oxygen tubing in a protective plastic bag when not in use for 2 (R5, R98) residents reviewed for respiratory care out on a total sample of 23 residents.