The violations at Norwalk Skilled Nursing & Wellness Centre affected medication safety for individual residents and food safety for nearly all 93 residents at the facility.
Licensed vocational nurse LVN 6 discovered the expired fluticasone/salmeterol inhaler for Resident 22 during the inspection on July 24. The inhaler had been opened May 4 and should have been discarded by June 4 according to manufacturer instructions requiring disposal within 30 days of opening.
"The facility failed to remove this inhaler from the medication cart once it expired," LVN 6 told inspectors. The nurse explained the medication treats breathing problems that "may get worse if the medication is less effective possibly causing the resident to be hospitalized."
The inhaler violation represented a broader failure to follow the facility's own medication storage policy, which requires immediate removal of "outdated, contaminated, or deteriorated medications."
Missing Blood Level Monitoring
Separately, staff ignored a pharmacist's recommendation to monitor blood levels for Resident 5, who was prescribed divalproex sodium for behavioral control. The resident had been taking the seizure medication since March 31 to manage "poor impulse control manifested by getting agitated easily leading to verbal and physical aggression."
On June 4, the consultant pharmacist specifically asked physicians to monitor Resident 5's valproic acid levels related to the medication use. No physician responded to the recommendation, and no laboratory monitoring was ever ordered or conducted.
Director of Nursing acknowledged the failure during the inspection. "The facility failed to respond to the pharmacist's request to monitor the valproic acid level for Resident 5's divalproex sodium use," the DON stated. "The facility failed to monitor the valproic acid level at any other time to ensure the medication was effective and not toxic."
The DON explained that failure to monitor could cause the medication to be "ineffective at controlling behaviors if the level is too low or could be toxic if the level is too high possibly leading to medical complications requiring hospitalization."
The facility's own Laboratory Monitoring Guidelines required serum drug levels of divalproex sodium to be monitored within 7-10 days after starting the medication or changing doses, then every six months thereafter.
Widespread Food Safety Problems
Inspectors found extensive food storage violations affecting all 93 residents during their review of kitchen areas. Multiple food items lacked proper dating, sealing, or refrigeration, with some items expired for months.
In the dry storage room, inspectors documented seven specific violations including expired pasta that should have been discarded, improperly stored condiments, and unsealed containers. Three items - penne pasta, orzo pasta, and soy sauce - had passed their expiration dates but remained in use.
"Opened and used penne pasta with no receiving date, open date of [DATE], used by date of [DATE]. It was expired according to its label," inspectors noted.
Several items requiring refrigeration after opening sat at room temperature, including lemon juice, Italian dressing, and soy sauce. Dietary Manager stated "all food items should have been labeled with receiving date when the facility got delivery from vendors" and acknowledged that "all expired items should have been discarded."
The violations extended to refrigerated and frozen storage areas. Inspectors found liquid coffee creamer in the refrigerator missing required dates, and hash browns in the freezer lacking an open date despite facility guidelines requiring all items to be properly labeled.
Language Barrier in Legal Documents
The facility also failed to properly explain arbitration agreements to residents and families. Resident 85's family member signed an arbitration agreement on May 17 without understanding its contents or implications.
Resident 85 had been diagnosed with dementia and altered mental status, with a July 21 physician assessment indicating she "does not have the capacity to understand and make decisions due to cerebral vascular disease." Her cognitive skills were rated as moderately impaired.
The family member told inspectors during a phone interview that she "did not remember signing the Arbitration and did not understand the Arbitration that was written in English." She thought she was signing routine admission paperwork and said "no one explained to her what the arbitration was."
The Admission Coordinator acknowledged the problem, stating "she realized the family and resident may not understand and it is important to ensure the representative and/or resident understand the Arbitration Agreement content."
The facility's own policy required staff to "explain the agreement to the resident in a form and manner that they understand, including in a language the resident understand and confirm that the resident understands the agreement."
Training Deficiencies
Inspectors found the facility failed to provide required dementia training to all staff members. Federal regulations require facilities to provide five hours of annual dementia-specific training to all employees beyond initial orientation requirements.
The Director of Staff Development confirmed that "all facility staff are to be in-serviced on dementia training two hours upon hire and six hours annually to prevent residents with dementia from being neglected or abused."
The Director of Nursing emphasized the importance of such training "to prevent nurse burnout and to educate staff on how to care for residents who are at a higher risk of being started on unnecessary medications."
The facility's October 2017 dementia care policy clearly stated the training requirements, specifying that "all staff will complete a minimum of 5 hours of Dementia specific in-service training per year" with documentation maintained in employee files.
The inspection violations collectively demonstrated systematic failures across medication management, food safety, resident rights, and staff training at the 93-bed facility. Each violation carried the potential for resident harm, from breathing complications due to ineffective expired medications to foodborne illness from contaminated food items.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Norwalk Skilled Nursing & Wellness Centre, LLC from 2024-07-26 including all violations, facility responses, and corrective action plans.