Norway Center For Health & Rehabilitation, LLC

Based on record reviews, interviews, and the Payroll Based Journal Report (PPJ), the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents for 1 of 4 quarters reviewed for weekend staffing (9/1/24 through 12/31/24). Findings: Review of Center for Medicare & Medicaid (CMS) PPJ Report revealed the facility triggered for low weekend staffing during the first quarter (10/1/24 through 12/31/24). During a review of first quarter weekend staffing with scheduler on 4/24/25 at 12:05 p.m., the scheduler confirmed the facility was not adequately staffed for 7 of 39 days reviewed. During a review of the daily staffing sheets with the Director of Nursing (DON) on 4/24/25 at 1:05 p.m., the above was confirmed. At this time DON stated she would have daily punches obtained for the days in question. The daily punches were not obtained by the end of survey.

Based on observation, interview, and review of the Culinary Services: Storage of Food & Supplies Policy and Procedure, revised 2/2022, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a hood, ceiling lights, a ceiling vent, and the walk-in refrigerator door; and failed to ensure foods were labeled and dated in a walk-in freezer for 1 of 1 kitchen tour for 1 of 1 day of survey (4/22/25). Findings: The facility's Culinary Services: Storage of Food & Supplies Policy and Procedure, revised 2/2022, noted: 2. Labeling and rotating food supply: a. Food products that are opened and not completely used or transferred from its original package to another storage container or prepared at the facility and stored should be labeled as to its contents and used by dates. 4. Food removed from its original container must be labeled with the common name of the food. On 4/22/25 from 9:00 a.m. to 9:30 a.m., an initial kitchen tour was conducted with the Food Service Director in which the following findings were observed: > The hood over the dish washing machine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record reviews, the facility failed to implement and maintain an effective training program for nursing staff contracted through the Clipboard Application (App), and NURSA App in the areas of dementia care, resident rights, neglect training by failing to ensure contracted Clipboard/NURSA Professionals (Users) completed training prior to independently providing services to residents for 3 of 3 contracted staff reviewed during a complaint investigation.( Staff #1,# 2, & # 4). Findings: Review of the Clipboard app Terms of Service Agreement last updated 10/9/23 states, Clipboard operates an online, marketplace, accessed through the Site, that allows third-party clients (each, a Client) to post open shifts at facilities (each, a Facility), and allows independent contractor professionals (each, a Professional) to view and sign up to work such shifts if they so choose. Under the subheading 2.1 CLIPBOARD'S ROLE AS A MARKETPLACE states, Clipboard merely makes the Site and Services available to enable Professionals and Clients to find and transact directly with each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide personal hygiene for 1 of 1 resident reviewed for Activities of Daily Living (ADL) (Resident #26). Findings: On 4/22/25 at 9:32 a.m., 4/23/25 at 12:09 p.m., and 4/23/25 at 2:20 p.m., Resident #26 was observed to have notable buildup on his/her bottom teeth. During an interview with Resident #26 representative stated [Resident #26] bottom teeth have build up on them, and resident can't brush them independently and further stated [Resident #26] used to insist on brushing their teeth when they were young, and it would bother resident to not have them clean. Review of Resident 26's care plan, updated 3/16/25 states: Personal Hygiene: partial/moderate assistance, helper provides less than half the effort. Oral Hygiene: set up/clean up assistance, helper provides set up/clean up assistance, . Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 3 of 15 indicating he/she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to obtain provider orders for the maintenance and monitoring of a pacemaker. In addition, the facility failed to initiate goals and interventions necessary for the presence of a pacemaker for 1 of 13 care plans (Resident #34). Findings: Resident #34 was admitted in 2/25 and has a diagnoses to include chronic heart failure, ischemic cardiomyopathy, hypertensive heart disease, and type II diabetes mellitus. Review of Resident #35's clinical record revealed appointment CM Heart 4/10/25 at 1:00 p.m. Review of Resident #34's clinical record NSG Admission/readmission Evaluation originally dated 2/20/25 section: Devices and treatments (care profile) is blank in subsection: pacemaker . Review of clinical record [[Hospital] Consultation Note] dated 2/14/25 revealed Resident #35 had a past medical history of presence of combination internal cardiac defibrillator (ICD) and pacemaker. Review of Resident #34's signed provider orders for April 2025 lacked evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 1of 1 resident reviewed for respiratory care (Resident #34). Findings: On 4/22/25 at 10:24 a.m., and 4/23/35 at 7:35 a.m., observations of Resident #34's nebulizer machine was observed on top of dresser with tubing and mask attached and resting on top of the nebulizer and not in a bag. Review of Resident #34's orders active for April 2025 revealed order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML3 ml inhale orally every 4 hours as needed for Wheezing or dyspnea; flu Lung sounds pre and post nebulizer treatment: C=Clear, D=Diminished W=Wheeze, bCR=Crackles R=Rhonchib Report abnormal lung sounds to RN for assessment. Document total min spent for nebulizer TX. Document Respiratory Rate before and after TX. Review of Resident #34's TAR dated April 2025 revealed nebulizer was last used 4/9/25. On 4/23/25 at 12:25 p.m., during an observation of Resident #34, Registered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to provide respiratory services as directed by physician orders related to nebulizer administration with monitoring for 1 of 3 residents reviewed who received nebulizer medications (Resident #27). Findings: On 2/13/22 at 12:57 p.m., observation of Resident #27 to have a nebulizer machine with tubing and face mask on the bed next to the pillow. Review of the medical record stated Resident #27 was admitted with acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, respiratory bronchiolitis interstitial lung disease, panlobular emphysema and dependence on supplemental oxygen. Physician orders dated, 2/2/23 for Ipratropium-Albuterol Solution 0.5-2.5 MG (milligram)/3ML (milliliter), 3 ml inhale orally four times a day for SOB (shortness of breath) or Wheezing with instructions for nursing to monitor Lung sounds pre and post nebulizer treatment: C=Clear, D=Diminished W=Wheeze, CR=Crackles R=Rhonchi. Report abnormal lung sounds to RN for assessment. Document total min spent for nebulizer TX…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary conditions on 1 of 2 wings ( C wing), the laundry room, the handicap bathroom, and the employee/public bathroom for 1 of 1 Environmental tours (6/10/2021). Findings: On 6/10/2021 from 8:50 a.m. to 9:15 a.m., a surveyor and the Maintenance Director conducted an tour of the facility in which the following findings were observed: C Wing: > Six(6) hallway ceiling vents were visibly dusty/dirty. > Resident room [ROOM NUMBER]- The floor was dirty around the base of the toilet. > Resident room [ROOM NUMBER]- The floor was dirty around the base of the toilet and along the edge of the walls. > Resident room [ROOM NUMBER]- The floor was dirty around the base of the toilet. > Resident room [ROOM NUMBER]- The floor was dirty around the base of the toilet. The privacy curtain, closest to the window, was in disrepair. > Resident room [ROOM NUMBER]-…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the food disposal, the wall air conditioner, the wall exhaust fan, the floors, and failed to label and date foods in the walk-in freezer for 1 of 1 kitchen tours on 1 of 3 days of survey. (6/7/2021) Findings: On 06/07/2021 between 6:20 p.m. and 6:55 p.m., during the kitchen tour, a surveyor and the Food Service Director observed the following: > The food disposal unit had dried liquid splatter on it. > The wall air conditioning unit was dusty/dirty. > The wall exhaust fan was dirty/dusty. > The dry goods storage room floor had dirt/debris and trash on it and under the shelving. > The walk-in freezer had an open unlabeled and undated bag of chicken strips, an unlabeled and undated bag of meat patties, and the floor had dirt/debris and trash on it under the shelving. On 06/07/2021 at 6:55 p.m., the Food Service Director confirmed the findings.

Based on observations and interviews, the facility failed to maintain the garbage storage area in a condition to prevent the harborage and feeding of pests on 2 of 4 days of survey. (6/7/2021 and 6/10/2021) Findings: 1. On 6/7/2021 at 6:20 pm, a surveyor and the Food Service Director observed the trash dumpster to have the left side door and the right side door open, exposing garbage bags. Additionally, there were used nursing gloves, papers, cigarette butts, old packing tape, and plastic cup lids on the ground around the dumpster. On 6/7/2021 at 6:30 pm, the Food Service Director confirmed the findings. 2. On 6/10/2021 at 8:30 a.m., a surveyor and the Food Service Director observed the trash dumpster to have the left side door open, exposing garbage bags. On 6/10/2021 at 8:30 a.m., the Food Service Director confirmed the findings.