Royal Norwell Nursing & Rehabilitation Center LLC

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for three Residents (#40, #13, #21), out of a total sample of 20 residents. Specifically, the facility failed:1. For Resident #40, to administer medications per physician's orders and crushing guidelines. Specifically, measure an accurate dose of MiraLAX per physician's order, administer Depakote DR per physician's order, and administer Seroquel and Zyprexa tablets per medication guidelines;2. For Resident #13, to ensure expired Lansoprazole (liquid compound for gastro-esophageal reflux disease (GERD)) was taken out of use/destroyed and not used for daily administration for 24 days after the use by date;3. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure drugs and biologicals were stored in accordance with State and Federal laws. Specifically, the facility failed to ensure:1. The Medication Cart remained locked when not in view and/or proximity of the nurse;2. For Resident #40, MiraLAX (medication for constipation) was not left at the bedside; and3. For Resident #50, crushed Ativan (controlled substance/anti-anxiety medication) was double locked and not crushed until administered.

Inspectors wroteBased on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for two Residents (#71 and #25) out of a sample of 17 residents. Specifically, the facility failed:1. To ensure that the staff wore the indicated personal protective equipment (PPE-items such as gowns and gloves worn by staff to decrease the spread of infections) when entering the room for Resident #71 on Contact Precautions (measures using protective barrier gowns and gloves as an infection control intervention designed to reduce transmission of methicillin-resistant Staphylococcus aureus (MRSA)); and 2. For Resident #25, to provide hand hygiene prior to meals.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #3), whose care plan indicated he/she required a Hoyer lift (mechanical mobility aid that supports a person's total body weight to allow movement from one surface to another safely) for transfer and Geri-sleeves (stocking like sleeve to protect fragile skin) to both upper extremities to minimize skin injury, the facility failed to ensure staff consistently implemented and followed interventions from his/her care plan, when on 12/07/24, Resident #3, was manually lifted and transferred from his/her bed into a wheelchair by Certified Nurse Aide (CNA) #2 and CNA #3 instead of utilizing the Hoyer lift, he/she also did not have the geri-sleeve on his/her right upper extremity, and as a result he/she sustained a skin tear to the right wrist which required four steri-strips to close the wound.

Inspectors wroteBased on records reviewed and interviews for two of three sampled residents (Resident #1 and #3), who both required a Hoyer Lift (mechanical mobility aid that supports a person's total body weight to allow movement from one surface to another safely) with the assistance of two staff members, the facility failed to ensure that necessary assistive devices were utilized properly and appropriately during transfers in order to maintain resident safety and prevent incidents/accidents resulting in injuries. 1) On 12/09/24, Certified Nurse Aide (CNA) #1 and Activity Assistant (AA) #1 (who was not a certified nurse aide or competent in mechanical lift transfers) did not check to see if the lower straps of the Hoyer lift sling/pad were properly connected to the Hoyer lift device, and during the transfer Resident #1 slid onto the floor, hitting his/her head. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice specific to following physician's orders for two Residents (#19 and #48) in a sample of 18 residents. Specifically, the facility failed: 1. For Resident #19, to follow physician's orders to discontinue an antipsychotic medication timely; and 2. For Resident #48, to ensure staff implemented physician's orders for: a. air mattress settings; b. 1:1 (one to one) supervision with oral intake; and c. fall mat to side of his/her bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the rights of one Resident (#60) to have fluids of choice, in a total sample of 18 residents. Specifically, the facility restricted the fluids of Resident #60, despite the removal of the order for a fluid restriction three weeks prior.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a reasonable accommodation was made for one Resident (#5), of 18 sampled residents. Specifically, the facility failed to ensure the call system was accessible to the Resident to call for staff assistance.

Inspectors wroteBased on record review and interviews, for one Resident (#36), of 18 sampled residents, the facility failed to implement policies and procedures for alleged abuse. Specifically, the facility failed to investigate and report an allegation of sexual abuse.

Inspectors wroteBased on record review and interviews, for one Resident (#36), of 18 sampled residents, the facility failed to ensure an allegation of sexual abuse was reported timely to the state agency as required.

Inspectors wroteBased on record review and interviews, for one Resident (#36), of 18 sampled residents, the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. Specifically, for Resident #36, the facility failed to ensure an allegation of sexual abuse was investigated.

Inspectors wroteBased on records reviewed and interviews, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed for one Resident (#21), out of a total census of 70 residents, to ensure safe storage of medications and biologicals according to current standards of practice.

Inspectors wroteBased on observation, interview, and policy review, for one Resident (#36), of 18 sampled residents, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, for Resident #36, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms to residents with increased risk).

Inspectors wroteBased on record review, document review, policy review, and interview, the facility failed to follow professional standards of practice in nursing for the care and monitoring of a peripherally inserted central catheter (PICC) and/or midline catheter. Specifically, the facility failed: 1. To obtain physician's orders and provide appropriate nursing interventions for 2 out of 2 PICC lines and 2 out of 2 midline catheter devices for one Resident (#20), out of a total sample of three residents with peripheral lines in place during the timeframe of 10/10/22 through 11/3/22. [...]

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure the proper care and treatment of a peripherally inserted central catheter (PICC) and/or midline catheter device in accordance with the facility policy/protocols. Specifically, the facility failed: 1. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure licensed nursing staff had the appropriate competencies and skill set for providing the necessary care and treatment for residents with a peripherally inserted central catheter (PICC- long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart that delivers fluids and/or medications) and/or midline catheter (thin, soft tube that is placed into a vein at the level of the armpit that delivers fluids and/or medications directly into the vein) device per facility policy and acceptable standards of practice and to ensure nursing practice by nursing students and their supervising nurse were adhered to for the administration of medications. Specifically, the facility failed: 1. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an environment free of accident hazards for two Residents (#71 and #64), out of a total sample of 24 residents, and for 5 out of 9 identified facility smokers, Residents (#34, #22, #2, #28, and #51). Specifically, the facility failed to ensure: 1. For Resident #71, had effective interventions implemented to prevent three unwitnessed falls, one of which resulted in a five-day hospitalization for a subdural hematoma (a pool of blood between the brain and its outermost covering) and comminuted mildly displaced nasal bone fracture (a fracture in which the bone is broken in several fragments. This type of fracture is typically caused by severe trauma/injury); 2. For Resident #64, hazardous items were not left at the bedside; and 3. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to follow professional standards of practice for food safety to prevent the potential spread of foodborne illness. Specifically, the facility failed to: 1. Ensure staff wore hair restraints in the main kitchen, during meal preparation and service, per the Food Code of the Food and Drug Administration (FDA) to prevent hair from contacting food; and 2. Properly label and/or store food items in the main kitchen's alcove, walk-in refrigerator, and two of two double door refrigerators so it was used by the use-by date or discarded.

Inspectors wroteBased on interview, record review, policy review, and review of the quality assurance and performance improvement (QAPI) plan, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and developed and implemented an appropriate corrective action plan to ensure satisfactory outcomes. Specifically, the facility failed to: 1. Track and analyze data, including the progress and outcome of projects identified in the facility's Quality Assurance and Performance Improvement Plan; and 2. [...]

Inspectors wroteBased on document review, policy review, record review, and interviews, the facility failed to maintain an infection prevention and control program as indicated in their infection control plan and policies. Specifically, the facility failed to maintain a complete and accurate system of surveillance and to analyze their collected surveillance data to identify any trends of actual or potential infections within the facility to validate the effectiveness of their program.

Inspectors wroteBased on documentation review and interview, the facility failed to provide mandatory effective communications training for direct care staff.

Inspectors wroteBased on documentation review and interview, the facility failed to provide training and education to their staff to outline elements and goals of the facility's Quality Assurance Performance Improvement (QAPI) program.

Inspectors wroteBased on documentation review and interview, the facility failed to provide behavioral health training and education to their staff.

Inspectors wroteBased on observation and interview, the facility failed to ensure protected health information was secured, and not printed on Missing Resident Profile Forms in an Elopement book that was kept in the facility's entrance area and accessible to anyone entering the building.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to ensure that pharmacy recommendations were reviewed and addressed for five Residents (#11, #44, #16, #70 and #34), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #11, to ensure the consultant pharmacist's recommendations were addressed for a Gradual Dose Reduction (GDR) of the antidepressant medication Trazodone; 2. For Resident #44, to ensure the consultant pharmacist's recommendations were addressed for safety and efficacy for the use of uric acid reducing medication; 3. For Resident #16, to ensure repeated pharmacy recommendations related to the use of an antihypertensive medication was addressed by the Physician; 4. For Resident #70, to ensure repeated pharmacy recommendations related to the use of an antipsychotic medication was addressed by the Physician; and 5. [...]

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure one Resident (#16) was free from a significant medication error, out of a total sample of 24 residents. Specifically, Resident #16 was administered his/her roommate's (Resident #175) medications by an unlicensed Nurse.

Inspectors wroteBased on review of the Facility Assessment and interview, the facility failed to implement staff educational resources (in-servicing) and competencies needed to care for residents receiving intravenous (IV) central line medications. Specifically, the facility failed to conduct the education and competency training required of all nursing staff to provide the appropriate care and treatment for residents with peripherally inserted central catheters (PICC- long, thin tube inserted through a vein in your arm and passed through to the larger veins near your heart) and midline catheter (thin, soft tube that is placed into a vein at the level of the armpit) devices used for intravenous (IV) antibiotic treatments per the Facility Assessment.

Inspectors wroteBased on record review, hospice contract review, and staff interview, the facility failed to ensure for one Resident (#49), out of a total sample of 24 residents, that hospice services were provided in accordance with the agreement between the hospice and the facility. Specifically, the facility failed to provide ongoing documentation and maintain a complete medical record of services to ensure prompt and effective communication and continuity of care for the Resident, in accordance with the hospice agreement.

Inspectors wroteBased on policy review, document review, and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring antibiotic use in line with the facility antibiotic stewardship program.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for three Residents (#3, #22, and #20), out of a total sample of five residents. Specifically, the facility failed to ensure that staff offered, assessed, and provided education on the recommended 20-Valent Pneumococcal Conjugate Vaccine (PCV20) (an active immunizing agent used to prevent infection caused by certain types of pneumococcal bacteria).

Inspectors wroteBased on observation, interview, and documentation review, the facility failed to implement an effective pest control program, as evidenced by mice sightings and mice droppings on 2 of 3 units and the dry storage room in the kitchen.

Inspectors wroteBased on observation, document review, and interview, the facility failed to ensure necessary trainings were completed, as indicated in their facility assessment.

Inspectors wroteBased on record review and interview, the facility failed to ensure Advance Directives were formulated and signed by the health care proxy (HCP), for one Resident (#38), out of a total sample of 24 residents.

Inspectors wroteBased on interview, document review, and policy review, the facility failed to complete their grievance process when verbal complaints were made by two Residents (#58 and #34), out of a total sample of 24 residents, resulting in a delay of resolution to the grievances. Findings Include: Review of the facility's policy titled Complaint/Grievance policy and procedure, dated as reviewed October 2022, indicated but was not limited to the following: - Voiced grievances are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff - the grievance official will complete the grievance within 72 business hours and submit to the Social Service Department and Administrator - the grievance official will complete the grievance form to include: [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure their abuse prevention policies were implemented for one Resident (#59), out of a sample of 24 residents. Specifically, the facility failed to follow their policy of reporting an allegation of abuse.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure an allegation of abuse by one Resident (#59), out of a total sample of 24 residents, was reported to the Department of Public Health's (DPH) Health Care Facility Reporting System (HCFRS) within the required two-hour timeframe.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#16), of a total sample of 18 residents. Specifically, the facility failed to ensure an allegation of neglect by a Nurse was thoroughly investigated according to facility policy.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure that staff developed and implemented a baseline care plan within 48 hours of the resident's admission, that included the instructions needed to provide effective and person-centered care to the resident that meet professional standards of quality care for two Residents (#71 and #125), in a total sample of 24 residents. Specifically, the facility failed to ensure: 1. For Resident #71, a baseline care plan was developed for the Resident's high fall risk; and 2. For Resident #125, a baseline care plan was developed for the Resident's code status.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for two Residents (#22 and #20), out of 24 sampled residents. Specifically, the facility failed to ensure: 1. For Resident #22, care plan interventions for safe smoking were implemented; and 2. For Resident #20, care plans were developed for the use of Peripherally Inserted Central Catheter(PICC)/midline catheter devices that were inserted in October 2022 and November 2022.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to implement the facility policy for the care of urinary catheters for one Resident (#125), with an indwelling catheter, out of total of 23 sampled residents. Specifically, the facility failed to maintain unobstructed urine flow and follow infection control practice to prevent the potential for infection for in use continuous drainage (CD) bags.

Inspectors wroteBased on observation, interview, and policy review, the facility failed for three Residents (#3, #34, and #24) to ensure respiratory equipment and tubing was managed and stored in a sanitary way to prevent the potential of contamination from environmental debris and germs. Specifically, the facility failed: 1. For Resident #3, to ensure respiratory nebulizer tubing and mouthpiece were stored in a sanitary manner; 2. For Resident #34, to provide the Resident with nebulizer tubing and set up that was free from exposure to environmental debris and germs when not in use and document the date equipment was changed or cleaned; and 3. For Resident #24, to ensure the proper care and storage of the Resident's respiratory equipment, including the cleaning of the oxygen concentrator and filter and storage of nebulizer equipment.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents are seen by the physician at least every 30 days for the first 90 days after admission and at least 60 days thereafter, with alternate visits by a nurse practitioner for one Resident (#22), of 24 sampled residents.

Inspectors wroteBased on the Beneficiary Protection Notification Review and interview, the facility failed to issue the appropriate Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-coverage (NOMNC) forms for two Residents (#39 and #1A), out of three residents sampled.