Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Norwich Springs Health Campus during CMS and state inspections, most recent first.
A resident with spinal surgery, DM2, CKD, morbid obesity, and spinal stenosis did not have timely coordination of an orthopedic follow-up despite the hospital AVS requiring it within two weeks. The record showed no evidence the appt was scheduled or attempted on time, and staff gave conflicting accounts about who was responsible for arranging the outside appt and transportation.
Infection control procedures were not followed for laundry handling, wound care, and Foley catheter care. Staff placed isolation laundry into standard trash bags, and yellow isolation bags were not available. During wound care for a resident with a pressure ulcer, the wound nurse and RN repeatedly contaminated gloves, scissors, supplies, and the wound area by touching environmental surfaces and clean items without proper hand hygiene or glove changes. For another resident with a Foley catheter, the drainage bag was observed resting on the floor inside a holder before and after care, contrary to the facility SOP and CDC guidance.
A resident with cirrhosis, ascites, mood disorder, and alcohol-induced major neurocognitive disorder, and with moderately impaired cognition, was observed sitting on a shower chair in a gown with buttocks exposed and visible from the hallway through an open room door. A CNA left the room quickly after hearing another resident yell and forgot to close the door or pull the privacy curtain, and an RN confirmed the exposure, demonstrating a failure to maintain the resident’s dignity and privacy.
Two residents receiving continuous oxygen therapy did not receive care in accordance with physician orders or facility policy. One resident with sepsis and pulmonary hypertension had an order for 3 L/min via nasal cannula, but surveyors observed the concentrator set at 2 L/min, which an RN confirmed was inconsistent with the order. Another resident with COPD and acute respiratory failure had an order for 2 L/min and monthly tubing changes; surveyors observed the nasal cannula hanging on the bed with prongs pressed against the bed surface, not stored in a sanitary bag, and a CNA placed it on the resident without replacing it. Later, an RN was observed with the concentrator set at 2.5 L/min, above the ordered rate, and did not adjust it, despite a policy requiring oxygen to be given as ordered and equipment kept clean and sanitary.
Failure to Document Nephrostomy Dressing Care: A resident with an indwelling urinary catheter, moderate cognitive impairment, and a newly placed right nephrostomy tube returned from the hospital with instructions to clean around the tube and change the dressing daily or when wet or dirty. After readmission, the chart contained no orders for nephrostomy dressing changes and no MAR/TAR documentation showing the dressing was changed, which was confirmed by the DHS during interview.
A resident with polyneuropathy and severe contractures required extensive to total assistance with ADLs and had orders for a PM&R consult for weakness and contractures. Staff made limited scheduling attempts, but the appointment was not completed, there was no documentation supporting alleged refusals, and the resident stated he had not been given the needed contact information or facility help to arrange the visit. The DON confirmed there were no additional attempts or follow-up to schedule the specialist appointment.
Antibiotic stewardship was not followed for two residents. One resident with dementia and other chronic conditions had urinary frequency and cloudy urine, but no fever, flank pain, suprapubic pain, dysuria, hematuria, or tenderness; despite this, the NP documented UTI, cited McGeer criteria, and started Levofloxacin. Another resident with lung cancer, malnutrition, and a history of C. difficile had a urine culture below the documented threshold, yet infection surveillance and the NP note still stated McGeer criteria were met and Levofloxacin was started. The ADON and DON confirmed both episodes did not meet McGeer criteria.
A resident admitted with a Stage 3 pressure ulcer did not receive appropriate wound treatment, as a protective cream unsuitable for deep wounds was used and no dressing was applied for several days. Additionally, multiple linen layers were used on a low air loss mattress, contrary to manufacturer recommendations for pressure injury care.
The facility failed to maintain a comprehensive water management plan, resulting in abnormal water test results in several areas. Despite the need for flushing and disinfection, these actions were not performed. The Legionella Water Management Plan lacked specific acceptable ranges for water quality measures, and facility documentation showed incomplete testing records. Corporate Maintenance confirmed the absence of necessary actions and specific measures in the plan.
The facility failed to implement comprehensive care plans for several residents, omitting necessary interventions for mobility aids, psychotropic medication use, and other specific needs. This included residents with cognitive impairments and those requiring extensive assistance for ADLs. Interviews confirmed these omissions, indicating a systemic issue in care plan development.
The facility failed to assess and obtain consents or orders for bed rail use for six residents, despite their need for extensive ADL assistance. The facility's policy requires assessments and informed consent, but these were not documented. The DON confirmed the absence of necessary records, indicating a systemic compliance failure.
A facility failed to ensure medications were not left at the bedside, affecting a resident who was cognitively intact and had multiple diagnoses. Medications were found unattended in the resident's room, and the LPN confirmed they were from the night shift. The facility's policy requires observation after administration to ensure ingestion, which was not followed.
The facility failed to ensure timely administration and proper documentation of consents for flu and pneumonia vaccines for three residents. A resident received a flu vaccine after a delay, another received a pneumonia vaccine without documented consent, and a third resident's pneumonia vaccine was not administered despite consent. The ADON confirmed the lack of evidence for these issues, contrary to facility policy.
A facility failed to include the use of bed rails in the baseline care plan for a resident with severe cognitive impairment and multiple medical conditions requiring extensive assistance. The omission was confirmed by MDS Support, despite the facility's policy requiring a 48-hour baseline care plan to be completed upon admission.
A facility failed to assess a resident's elopement risk before removing a Wanderguard bracelet, which was part of the care plan for a resident with severe cognitive impairment and a history of exit-seeking behaviors. Despite a physician's order for daily checks and a policy requiring regular assessments, the bracelet was removed without documentation or reassessment, as confirmed by staff interviews.
A resident with a urinary catheter was found using a leg bag at bladder level, contrary to the care plan requiring the bag to be below the bladder. The facility did not provide leg bags, and the one in use was from a recent hospital discharge. An RN confirmed the setup was incorrect, leading to improper catheter management.
A resident with type two diabetes received an incorrect insulin dose due to an LPN's failure to prime the insulin pen before administration. The LPN was unaware of the requirement to prime the pen, as specified in the manufacturer's instructions, which led to a significant medication error.
Delayed Coordination of Orthopedic Follow-Up Appointment
Penalty
Summary
The facility failed to ensure timely coordination of an outside orthopedic follow-up appointment for a resident who had been hospitalized for spinal surgery. The resident had diagnoses including type II diabetes mellitus, chronic kidney disease, morbid obesity, and spinal stenosis, and the MDS indicated mild cognitive impairment. The hospital AVS dated 05/01/26 stated the resident needed an orthopedic follow-up within two weeks, but the medical record showed no evidence that the appointment was scheduled or even attempted within that timeframe. A nursing progress note dated 05/25/26 documented that the resident should have a follow-up appointment with the orthopedic surgeon and that the facility should call to make the appointment and arrange transportation. A physician order dated 05/27/26 later showed an orthopedic appointment scheduled for 05/28/26 at 1:20 P.M. During interview, the resident stated that the SSD said she would schedule the orthopedic appointment and arrange transportation. The SSD stated she did not arrange outside physician appointments and instead relayed the request to the medical records nurse. The orthopedic office reported that the facility’s first contact about the appointment was not until 05/26/26, when a voicemail was received, and the appointment was then scheduled for 06/01/26 before being moved up at the facility’s request.
Infection Control Failures in Laundry, Wound Care, and Foley Catheter Care
Penalty
Summary
The facility failed to follow infection control procedures for laundry handling. During interviews, housekeeping and CNA staff described that laundry from contact isolation rooms was being placed into standard trash bags rather than yellow isolation bags, and that laundry staff could not tell which items needed separate washing. One CNA stated that dirty linen, including linen from contact isolation rooms, was placed in standard trash bags with no identifying differences and taken to the dirty linen room. Another CNA stated she was unable to locate any yellow isolation bags anywhere in the facility, including soiled linen rooms, active contact isolation rooms, and the laundry room. The facility also failed to maintain infection control during wound care for a resident with a pressure ulcer. The resident had diagnoses including malignant neoplasm of the right bronchus or lung, severe protein calorie malnutrition, chronic respiratory failure with hypoxia, and sepsis, and was dependent on staff for most ADLs. The resident had physician orders for ongoing wound care to the right pinky plantar wound, and the care plan required enhanced barrier precautions with hand hygiene before and after care, PPE use, and infection control practices. During observation of the wound dressing change, the wound nurse and RN repeatedly touched environmental surfaces, the resident, and wound care supplies with the same gloves, used scissors that had been placed on a chair and windowsill without cleaning them, and handled clean and soiled materials together. Gloves were not changed after contact with contaminated surfaces, and hand hygiene was not performed at key points during the procedure. The facility further failed to follow infection control procedure for indwelling urinary catheter care for a resident with mechanical complication of an indwelling urethral catheter, neuromuscular dysfunction of bladder, and kidney stone. The resident had moderate cognitive impairment and an order for Foley catheter care every shift with instructions to monitor proper placement of the leg securement device. During observation, the Foley catheter drainage bag was resting on the floor inside a blue urinary drainage bag holder before and after catheter care. The facility’s catheter care SOP stated the catheter tubing and drainage bag are to be kept off the floor, and CDC guidance reviewed in the report stated the urinary drainage bag should not rest on the floor.
Resident Left Exposed and Visible From Hallway Due to Failure to Maintain Privacy
Penalty
Summary
The facility failed to ensure resident dignity and privacy when a cognitively impaired resident was left exposed and visible from the hallway. The resident, who had diagnoses including cirrhosis with ascites, mood disorder, and alcohol-induced major neurocognitive disorder, had a BIMS score of eight, indicating moderately impaired cognition. During an observation, the resident was seen sitting on a shower chair in a gown with buttocks exposed, and this exposure was visible from the open room door in the hallway. A Certified Resident Care Associate and a Registered Nurse confirmed that the resident’s buttocks were visible from the hallway. The Certified Resident Care Associate reported that she had left the resident’s room quickly after hearing a resident in an adjacent room yell and, in her haste, forgot to close the door or pull the privacy curtain, resulting in the resident’s exposed state being visible to others. This incident involved one resident out of three reviewed for dignity, in a facility with a census of 52 residents, and was identified through record review, observation, and staff interviews.
Failure to Follow Oxygen Orders and Maintain Sanitary Oxygen Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy services according to physician orders and to maintain oxygen equipment in a sanitary condition for two residents. For one resident with sepsis due to MRSA and pulmonary hypertension, the MDS indicated continuous oxygen use and a physician order dated 3/11/26 specified oxygen at 3 L/min via nasal cannula continuously. On observation, the oxygen concentrator gauge showed delivery at 2 L/min while the resident was resting in bed. A concurrent interview with the RN present confirmed the oxygen was set at 2 L/min, and the RN further confirmed that the physician’s order required 3 L/min. The facility’s SOP for Administration of Oxygen directed staff to verify the physician’s order and to administer oxygen as ordered. For another resident with diagnoses including paroxysmal atrial fibrillation, GI hemorrhage, acute respiratory failure with hypoxia, and COPD, the admission MDS showed the resident was cognitively intact and receiving oxygen therapy. Physician orders dated 2/23/26 required oxygen at 2 L/min via nasal cannula continuously and monthly tubing changes. During observation, the nasal cannula was found hanging on the side of the bed, not stored in a sanitary bag, with the nasal prongs pressed against the side of the hospital bed. A CNA present then placed the same nasal cannula on the resident without replacing it and confirmed it should have been stored in a sanitary bag when not in use. A subsequent observation with an RN showed the oxygen concentrator set at 2.5 L/min, above the ordered 2 L/min, and the RN confirmed the discrepancy without making an adjustment. The facility’s oxygen administration policy required oxygen to be administered as ordered and equipment to be maintained in a clean and sanitary manner when not in use.
Failure to Document Nephrostomy Dressing Care
Penalty
Summary
The facility failed to follow care instructions for nephrostomy care for Resident #02. The resident was admitted with diagnoses including mechanical complication of an indwelling urethral catheter, neuromuscular dysfunction of the bladder, and kidney stone, and the MDS indicated the resident used an indwelling urinary catheter and had moderate cognitive impairment. After hospital discharge with a right nephrostomy tube, the resident’s care instructions directed staff to clean around the tube and change the dressing daily or as instructed, and to change it if it became wet or dirty. After the resident was readmitted to the facility, the medical record from 12/16/25 through 01/21/26 contained no orders to change the dressing around the nephrostomy site. The MAR and TAR for that same period also contained no documentation of dressing changes being completed around the nephrostomy site. During interview, the Director of Health Services confirmed there were no documented occurrences of dressing changes around the nephrostomy site for Resident #02 during that time. The facility’s clinical SOP for urinary catheter care did not define a minimum frequency of dressing changes for catheter sites, and it directed staff to determine whether changes in daily urinary catheter care procedures had been made.
Failure to Schedule PM&R Appointment for Resident With Contractures
Penalty
Summary
The facility failed to ensure a specialist appointment was scheduled for a resident with polyneuropathy, bilateral knee contractures, and a left upper arm muscle contracture. The resident’s annual MDS indicated he was cognitively intact and required extensive to total assistance with dressing, hygiene, and mobility. Physician orders dated 02/01/2025, 10/10/2025, and 12/19/2025 directed a consult with a community provider for Physical Medicine and Rehabilitation for evaluation and treatment related to weakness and contractures, but the care plan did not include interventions related to splint use, contracture management, or follow-up for specialty consultation. Therapy documentation showed the resident had severe wrist contractures, including a left wrist flexion contracture measured at -70 degrees that remained unchanged, and the Rehab Director stated no splint could be applied due to the severity of the impairment. Nursing notes showed staff attempted to schedule the appointment and were told the provider had retired, and later that the appointment would not be scheduled due to reported prior refusals, but no documentation supported any refusals. The resident stated he had not been sent to a specialist, had not previously been given the contact number to schedule, and needed facility assistance to arrange the appointment. The DON confirmed there was no evidence of additional attempts to schedule the appointment and that the facility did not follow up to assist the resident in scheduling it.
Antibiotic stewardship not followed for two residents
Penalty
Summary
The facility failed to ensure antibiotic stewardship was followed for two residents reviewed for antibiotic use. One resident, admitted with diagnoses including dementia, pulmonary fibrosis, anxiety, and pleural effusion, had a urine culture positive for Klebsiella aerogenes after reporting urinary frequency and cloudy urine. The Nurse Practitioner documented urinary frequency and urgency, noted the resident denied fever, chills, flank pain, suprapubic pain, dysuria, hematuria, or other systemic signs of infection, and recorded no suprapubic or costovertebral angle tenderness. Despite these findings, the NP documented urinary tract infection and started Levofloxacin for three days, referencing McGeer criteria as met based on the symptoms and culture results. During interview, the ADON confirmed the UTI did not meet McGeer criteria and stated staff were aware the clinical criteria were not actually met even though the provider documentation was used to justify antibiotic initiation. A second resident, with diagnoses including malignant neoplasm of the right bronchus or lung, severe protein-calorie malnutrition, aneurysm of other specified arteries, and a history of C. difficile enterocolitis, had infection surveillance documentation stating a UTI met McGeer criteria based on a urine culture threshold of 100,000 CFU/mL. The actual urine culture showed 10,000 to 50,000 CFU/mL growth of Proteus mirabilis, Pseudomonas aeruginosa, and Enterococcus faecalis, which was below the threshold documented in the infection tracker. A provider progress note documented urinary frequency and intermittent dysuria, described the resident as high risk for progression to severe infection due to a history of septic UTI, and initiated Levofloxacin for three days while stating McGeer criteria were met. The ADON and DON both confirmed the November UTI did not meet McGeer criteria based on the culture results and resident presentation, and the ADON stated concerns had previously been discussed with the NP regarding antibiotic initiation without meeting criteria.
Failure to Provide Appropriate Pressure Ulcer Treatment and Mattress Use
Penalty
Summary
A Stage 3 pressure ulcer was present upon admission for a resident with diagnoses including hypertensive chronic kidney disease and peripheral vascular disease. The wound, located on the coccyx, was documented as having serosanguineous drainage and surrounding discoloration. The care plan included interventions such as a pressure reducing mattress and treatment per physician order. However, the initial physician order was for a protective cream to be applied after incontinence episodes, which was not appropriate for a deep wound as indicated by the product's warning label. No dressing was used to cover the pressure ulcer until several days after admission, despite the wound's severity. Additionally, during wound care observation, the resident was found on a low air loss mattress with a fitted sheet, a cloth bed pad, and an incontinence brief, resulting in multiple layers between the resident and the mattress. The mattress user manual specifically recommended avoiding multiple layers of linens or underpads to promote healing of pressure injuries. Staff interviews confirmed that the protective cream was used as a routine order and that multiple layers were present, contrary to manufacturer guidelines. These actions and inactions led to the deficiency cited in the report.
Deficient Water Management Plan and Testing
Penalty
Summary
The facility failed to maintain a comprehensive water management plan, which included monitoring measures and acceptable ranges for water quality. A review of microbiological analyses revealed that several areas within the nursing facility and connected assisted living had abnormal water test results. Specifically, two areas in the nursing facility required site flushing and consideration of disinfection, while five areas required immediate site disinfection. Additionally, five out of six areas in the assisted living section also tested in the abnormal range, necessitating flushing and disinfection. Despite these findings, the facility did not perform the necessary flushing or disinfection procedures. The Legionella Water Management Plan lacked specific information on acceptable ranges for water quality measures such as hardness, total alkalinity, and pH levels. Facility documentation showed some weekly temperature logs but no acceptable limits or evidence of monthly testing for water hardness, alkalinity, and pH. During an interview, the Corporate Maintenance staff confirmed the absence of flushing or disinfection despite abnormal test results and acknowledged the lack of specific measures or ranges in the water management plan. The facility's policy on water management required procedures to reduce Legionella risk and establish control measures, but these were not effectively implemented.
Deficiencies in Care Plan Implementation
Penalty
Summary
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific care needs. For Resident #27, the care plan lacked interventions related to the use of mobility bars, which are crucial for the resident's mobility and safety. Similarly, Resident #34's care plan did not include interventions for psychotropic medication use or mobility bars, despite the resident requiring extensive assistance for activities of daily living (ADL). Resident #36's care plan also omitted necessary interventions for mobility bars, which were noted as potential enablers for safe transfers and increased mobility. Resident #190, who had severe cognitive impairment and required extensive ADL assistance, did not have a care plan addressing psychotropic drug use or mobility bars. Resident #194's care plan was similarly deficient, lacking interventions for mobility bars and psychotropic drug use, despite the resident's cognitive intactness and extensive ADL assistance needs. Interviews with facility staff confirmed these omissions, highlighting a systemic issue in care plan development and implementation. Additional deficiencies were noted for Resident #3, whose care plan did not address hearing loss or the use of hearing aids, despite physician orders and family requests. Resident #13's care plan failed to include information about a prescribed splint for contracture management, and Resident #28's care plan was not updated to reflect wandering behaviors and the use of a wander guard, even after an elopement incident. These omissions indicate a failure to update care plans to reflect current needs and interventions, as required by facility policies.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess and obtain consents or orders for the use of bed rails for six residents. These residents, identified as #27, #34, #36, #190, #194, and #196, were all reviewed for bed rail use. The facility's policy requires an individualized nursing observation upon admission, quarterly, and as needed, to address the need for a safety device, medical symptoms for use of the device, and whether the device restricts movement. However, the facility did not complete these assessments or obtain informed consent for the use of bed rails for the residents in question. The medical records of the residents revealed that they required extensive assistance for activities of daily living (ADL), with some residents being cognitively intact and others having severe cognitive impairment. Despite these needs, there were no documented bed rail assessments, informed consents, or physician orders for the use of bed rails. The Director of Nursing confirmed during interviews that the necessary assessments and consents were not present in the electronic health records, indicating a systemic failure to comply with the facility's policy on restraint/enabler use.
Medications Left Unattended at Bedside
Penalty
Summary
The facility failed to ensure medications were not left at the bedside, affecting one resident. Resident #30, who was cognitively intact, was admitted with multiple diagnoses including multiple sclerosis, anemia, shock, gastrointestinal hemorrhage, sepsis, hypertensive heart disease with heart failure, congestive heart failure, non-ST elevation myocardial infarction, pleural effusion, and cardiomyopathy. The resident had physician orders for several medications to be administered between 7:00 P.M. and 11:00 P.M., which were marked as given on the Medication Administration Record for May 2024. During an observation, six medications were found in a medication cup at the bedside of Resident #30, who was not present in the room. An LPN confirmed the presence of the medications and stated she did not administer them. The Director of Nursing verified that the medications were from the night shift medication pass. The facility's policy on medication administration requires that residents be observed after administration to ensure the dose is ingested, and any partial ingestion should be noted on the MAR, which was not adhered to in this case.
Failure to Ensure Timely Vaccination and Consent Documentation
Penalty
Summary
The facility failed to ensure that signed consents were completed and vaccinations were administered timely for flu and pneumonia vaccines, affecting three residents. Resident #28 consented to receive the flu vaccine on two occasions, with the first consent dated 07/25/23 and the vaccine administered on 10/30/23, indicating a delay. Additionally, the pneumonia vaccine was administered on 08/19/23 after a phone call on 08/14/24, suggesting a documentation error in the date. Resident #14 received a pneumonia vaccine on 06/28/23, but the facility could not provide evidence of a signed consent for this vaccination. Resident #25 consented to receive the pneumonia vaccine on 11/01/23, but there was no evidence of administration, and the record stated the vaccine was refused without proper documentation of refusal or consent. During an interview, the ADON confirmed the lack of evidence for the administration of the pneumonia vaccine for Resident #25 and the absence of signed consents for Residents #28 and #14. The facility's policy required signed informed consent for immunizations, which was not adhered to in these cases.
Failure to Address Bed Rails in Baseline Care Plan
Penalty
Summary
The facility failed to address the use of bed rails on the baseline care plan for a resident admitted with multiple diagnoses, including severe cognitive impairment and extensive assistance needs for activities of daily living. The resident's medical record indicated a need for mobility assistance due to conditions such as a wedge compression fracture, displaced intertrochanteric fracture, cardiac arrhythmias, dementia, depression, hypertension, pain, and a history of falls. Despite these needs, the baseline care plan created within 48 hours of admission did not include the use of bed rails or mobility bars, which were later noted in the resident's profile care guide. This omission was confirmed during an interview with MDS Support, who acknowledged that the enabler/mobility bars were not checked on the baseline care plan upon admission. The facility's policy required a 48-hour baseline care plan to be completed within 48 hours of admission, serving as a temporary working care plan until the comprehensive care plan was finalized.
Failure to Assess Elopement Risk Before Wanderguard Removal
Penalty
Summary
The facility failed to ensure a resident was properly assessed before the removal of a Wanderguard bracelet, which is used to prevent wandering and elopement. This deficiency affected a resident with a history of dementia, heart disease, and severe cognitive impairment, who was identified as being at risk for elopement. The resident's care plan included the use of a Wanderguard bracelet due to exit-seeking behaviors, and a physician's order required daily checks of the bracelet's function. Despite these precautions, the Wanderguard bracelet was removed without any documented assessment indicating that the resident was no longer at risk for elopement. Interviews with facility staff, including a registered nurse and the administrative team, revealed that there was no documentation or assessment conducted prior to the removal of the Wanderguard bracelet. The facility's policy required elopement risk assessments upon admission, quarterly, and upon any change in condition, but this protocol was not followed in this instance. The lack of assessment and documentation before the removal of the Wanderguard bracelet represents a failure to adhere to the facility's own policies and procedures for managing residents at risk of elopement.
Improper Catheter Bag Use for Resident
Penalty
Summary
The facility failed to ensure the correct catheter bag was used for a resident, leading to a deficiency in catheter care. Resident #28, who was admitted with a primary diagnosis of urinary tract infection and secondary diagnoses including infection due to an indwelling urethral catheter, was observed with a leg bag at bladder level. This was contrary to the care plan, which required the urinary bag to be maintained below the bladder to prevent urine reflux. The resident's medical history also included chronic kidney disease and benign prostatic hyperplasia with lower urinary tract symptoms. Observations on two occasions revealed that the urine was not flowing freely into the catheter bag, indicating improper catheter management. During an interview, RN #118 confirmed that the facility does not provide leg bags and that the leg bag in use was from the resident's recent hospital discharge. The nurse acknowledged that the leg bag should have been replaced with a regular catheter bag and confirmed that the current setup was incorrect, as the catheter should be positioned below the bladder level.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving the administration of insulin to a resident. The resident, who was admitted with a diagnosis of type two diabetes, was observed receiving six units of lispro insulin from an LPN. The LPN did not prime the insulin pen before administration, which is a necessary step to remove air from the needle and cartridge and ensure the correct dosage is delivered. During an interview, the LPN confirmed that she did not prime the pen and was unaware of the requirement to do so. The manufacturer's instructions for the insulin lispro KwikPen clearly state the importance of priming the pen before each injection to avoid administering an incorrect dose.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hilliard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Darby Glenn Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 4 | 0 |
| Trueman Pointe Care Center | 1.2 mi | ★★★★★ | 6 | 0 |
| Mill Run Care Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Mayfair Village Nursing Care Center | 3 mi | ★★★★★ | 16 | 0 |
| The Sanctuary At Tuttle Crossing | 3.2 mi | ★★★★★ | 3 | 0 |
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