Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Norridge Gardens during CMS and state inspections, most recent first.
Staff did not consistently implement fall precautions for two residents at high risk for falls, as evidenced by beds not being kept at the lowest position and call lights and personal items being out of reach. Multiple staff, including an LPN and CNA, confirmed these lapses during observations and interviews, despite care plans and fall risk assessments indicating the need for these interventions.
The facility failed to follow its Water Management Program, lacking documentation for legionella testing and monitoring in unoccupied rooms. Additionally, staff did not adhere to PPE and hand hygiene protocols, with a nurse administering medications to a resident on contact precautions for MRSA without an isolation gown, and staff not changing gloves or performing hand hygiene during resident care.
The facility failed to provide adequate grooming and hygiene care to residents dependent on staff for ADLs. Observations revealed residents with long, dirty fingernails, overgrown facial hair, and soiled incontinence briefs. Despite being present, staff did not address these issues, contradicting the facility's stated practices.
The facility failed to label and date medications properly and ensure accurate narcotic counts. Insulin and Ozempic were found opened and undated, and discrepancies were noted in narcotic logs for several residents. Staff personal items were also improperly stored in medication carts.
Two residents in a facility were not provided with appropriate splinting for their contractures as per physician orders. One resident with severe cognitive impairment and hemiplegia was found without a splint on his contracted hand, causing pain during attempts to open it. Another resident was observed multiple times without a required hand splint due to staff oversight, despite physician orders and facility policy.
The facility failed to provide safe transfer and feeding supervision to residents requiring assistance with ADLs. A resident with multiple diagnoses was assisted to the bathroom without a gait belt, contrary to the care plan. Another resident with morbid obesity and Alzheimer's was also transferred without a gait belt. Additionally, a resident with Parkinson's and dementia was left unsupervised during meals, against dietary instructions. These actions were inconsistent with care plans and standard practices.
Two residents did not receive the prescribed double protein portions during meal service. Despite physician orders and care plans indicating the need for double protein at lunch, both residents were served single portions of mechanical soft polish sausage. The dietary manager acknowledged the error, and the dietitian confirmed the double protein recommendation due to food preference and history of weight loss.
The facility failed to offer the PCV20 vaccine to three residents who were eligible, despite having received the PCV13 vaccine. The residents, with various chronic conditions, were not documented as having been offered or refused the additional vaccine, contrary to the facility's policy and CDC guidelines.
The facility failed to make survey results readily available for residents, affecting all 206 residents. During a resident council meeting, attendees reported never seeing a binder with survey results. Observations confirmed the absence of such a binder in common areas. The administrator was unable to locate the binder, confirming the deficiency.
Two residents in the facility did not receive showers twice a week as per policy. One resident, with multiple health conditions, was scheduled for baths twice weekly but reported only receiving them once due to staff time constraints. Documentation inaccurately showed refusals, with no nursing notes to confirm. Another resident, requiring substantial assistance, also reported staff being too busy to provide showers, with documentation incorrectly indicating refusals. Both residents expressed that staff claimed they had no time or it was not their scheduled day, contrary to facility policy.
A resident with moderately impaired cognition was found with medications left at their bedside, contrary to facility policy requiring staff to remain until all medications are taken. The incident involved typical morning medications, and the responsible RN claimed to have observed the resident taking them, despite evidence to the contrary.
The facility failed to provide timely incontinent care to two residents with cognitive impairments, resulting in them being found with heavily soiled and discolored briefs. The care plans for both residents included interventions for the risk of impaired skin integrity, which were not followed.
A nurse and a CNA were observed performing a straight catheterization on a resident without cleaning the labia area and without using sterile gloves. The resident had a history of UTIs and required catheterization every four hours. The Director of Nursing confirmed that the staff did not follow the proper guidelines for catheter care.
The facility failed to provide timely incontinence care for three residents requiring extensive assistance. Residents were found with saturated incontinence briefs and wet sheets, indicating that care was not provided as per the care plans and facility policy, which required checks every two hours.
Failure to Implement Fall Precautions for High-Risk Residents
Penalty
Summary
Facility staff failed to implement fall precautions for two residents identified as high risk for falls. One resident was observed multiple times with her bed not in the lowest position, her call light out of reach, and personal items such as water inaccessible. This resident had a history of multiple falls and her care plan specified that her bed should be kept at the lowest position and her call light within reach. Staff, including an LPN and CNA, confirmed these deficiencies during interviews and observations. The resident was also noted to have a bandaged arm and some confusion, further increasing her vulnerability. Another resident was found sitting on her bed with her feet on the floor, unable to reach her call light, which was tied to a grab bar and hanging to the floor. She expressed the need for assistance to use the bathroom but could not call for help due to the call light's placement. Staff interviews confirmed that fall precautions for residents with a history of falls include keeping beds at the lowest position and ensuring call lights and personal items are within reach. These precautions were not consistently implemented, as evidenced by direct observation and staff acknowledgment.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its Water Management Program, which is designed to reduce the risk of Legionnaire's disease. The Maintenance Director admitted that while monthly water quality tests are performed using a TDS probe, the results are not documented, and there is no evidence of legionella testing prior to December 4, 2024. Additionally, the facility lacks documentation for daily flushing, water temperature, or chlorine level monitoring in unoccupied rooms, as required by their policy. The facility also did not follow its policy for Personal Protective Equipment (PPE) during the care of a resident in contact isolation. A nurse administered medications to a resident on contact precautions for MRSA without wearing an isolation gown, only using gloves. The nurse was unsure of the specific contact precautions required for the resident, indicating a lack of adherence to the facility's infection control protocols. Furthermore, the facility failed to comply with its hand hygiene and glove use policy during resident care. Two separate incidents were observed where staff members did not change gloves or perform hand hygiene between tasks, despite providing personal care to residents. This non-compliance with standard infection control practices poses a risk of spreading infections among residents.
Deficiencies in Resident Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide adequate incontinence care, oral care, and grooming to residents who were dependent on staff for these activities of daily living (ADLs). Observations revealed that several residents had long, untrimmed fingernails with black or brown substances underneath, indicating a lack of regular nail care. Additionally, some residents had overgrown facial hair, which was not addressed despite being unbecoming and against the facility's grooming standards. These deficiencies were observed in residents with severe cognitive impairments and those requiring maximum assistance for self-care activities. Specific instances included a male resident with hemiplegia and dementia who was found with a heavily soiled incontinence brief and dry stool stuck to his skin, requiring extensive cleaning. His fingernails were long and dirty, and his skin was extremely dry and flaky. Another resident with Parkinson's disease and dementia was observed with long facial hair and unkempt fingernails, despite being dependent on staff for grooming. Similar issues were noted in other residents, including those with Alzheimer's disease and other cognitive impairments, who were seen with long chin hairs and dirty, jagged fingernails. The facility's policies for ADLs, including nail care and shaving, were not adhered to, as evidenced by the repeated observations of residents with poor hygiene and grooming. Staff members, including CNAs and nurses, were present during these observations but did not take action to address the deficiencies. The Director of Nursing acknowledged the facility's practice of ensuring residents are well-groomed, yet the observed conditions of the residents contradicted this practice.
Medication Labeling and Narcotic Count Deficiencies
Penalty
Summary
The facility failed to properly label and date medications, as well as ensure accurate accounting of narcotic medications. During an inspection, it was observed that a Basaglar Kwik Pen and Insulin Lispro were opened and not dated, contrary to pharmacy recommendations that require these medications to be discarded after a certain period once opened. Additionally, a vial of Ozempic was found opened and undated in the refrigerator. The facility's policy requires medications to be labeled and stored to monitor potency and expiration dates, which was not adhered to in these instances. Furthermore, discrepancies were found in the narcotic medication counts for several residents. The narcotic logs did not match the actual number of tablets present for medications such as Lorazepam, Hydrocodone/APAP, and Alprazolam. The Assistant Director of Nursing stated that staff are required to sign out narcotic medications on the narcotic sheet immediately after administration to ensure accurate counts. However, this practice was not consistently followed, leading to discrepancies in the narcotic logs. Additionally, personal belongings of staff were improperly stored in medication carts, which is against the facility's policy.
Failure to Apply Splints and Assess Contractures
Penalty
Summary
The facility failed to assess and treat a resident with a contracture of the left hand and did not apply a splint as per physician orders. One resident, a male with severe cognitive impairment and multiple diagnoses including hemiplegia and hemiparesis, was observed without a splint or positioning device on his contracted left hand. The restorative nurse was unaware of the contracture, and the occupational therapist later recommended a resting hand splint to prevent further deterioration. Despite the recommendation, the resident experienced pain when staff attempted to open his contracted hand. Another resident, with diagnoses including hemiplegia and hemiparesis, was not wearing a right hand splint as ordered by the physician. The order specified the splint should be applied in the morning and removed in the evening, with monitoring for pain. However, the resident was observed without the splint on multiple occasions, and a CNA admitted to forgetting to apply it. The facility's policy on the application of splints was not followed, contributing to the deficiency.
Failure in Safe Transfer and Feeding Supervision
Penalty
Summary
The facility failed to provide safe transfer and feeding supervision to residents requiring assistance with activities of daily living (ADL). One resident, identified as R58, who has multiple diagnoses including a displaced fracture and Parkinson's disease, was assisted to the bathroom by a CNA without the use of a gait belt, despite the care plan indicating the need for extensive assistance by two staff members and the use of a gait belt during transfers. This resident was also assessed to be at risk for falls. Another resident, R24, with diagnoses including morbid obesity and Alzheimer's disease, was similarly assisted to the toilet by a CNA without a gait belt, contrary to the care plan that required two staff members and a gait belt for transfers. The resident's fall assessment indicated a risk for falls, and the Director of Nursing confirmed the standard practice of using a gait belt for residents requiring assistance. Additionally, R42, who has Parkinson's disease and dementia, was left unsupervised during meals despite requiring feeding assistance and having specific dietary instructions to avoid straws and alternate consistencies. The resident was observed eating without supervision and using a straw, which was against the care plan and dietary recommendations. The Speech Language Pathologist had previously recommended direct supervision during meals for safety and encouragement of oral intake due to the resident's swallowing difficulties and cognitive impairments.
Failure to Provide Prescribed Double Protein Portions
Penalty
Summary
The facility failed to provide the prescribed double protein portions for two residents during meal service. On December 17, 2024, during tray line service, a dietary aide served a resident a single portion of mechanical soft polish sausage instead of the double protein portion ordered by the physician. The dietary manager was informed of the discrepancy, but the resident's meal ticket only showed a single portion. The resident's care plan and physician order summary indicated a need for a therapeutic diet with double protein at lunch. Another resident also received a single portion of mechanical soft polish sausage, despite having a diet order for double protein at lunch. The dietary manager acknowledged the error and stated that the meal ticket would be updated. The resident's care plan noted nutritional problems related to weight changes and required serving the diet as ordered. The dietitian confirmed the double protein recommendation for both residents, one due to a food preference and the other due to a history of weight loss. The facility's diet spreadsheet and serving scoop chart confirmed the portion sizes, but the prescribed double protein portions were not provided.
Failure to Offer Pneumococcal Vaccine to Eligible Residents
Penalty
Summary
The facility failed to adhere to its policy of offering the pneumococcal vaccine to residents, as evidenced by the cases of three residents who were not offered the PCV20 vaccine despite being eligible. Resident R63, with diagnoses including dementia and chronic obstructive pulmonary disease, was admitted to the facility and had only received the PCV13 vaccine. The facility's Infection Preventionist Nurse confirmed that R63 had not been offered the PCV20 vaccine, which should have been administered according to the facility's policy and CDC guidelines. The Immunization Audit Report for R63 did not document any offer or refusal of the additional pneumococcal vaccine. Similarly, Resident R79, with conditions such as chronic atrial fibrillation and asthma, had also only received the PCV13 vaccine and was not offered the PCV20. The Immunization Audit Report for R79 lacked documentation of any offer or refusal of the PCV20 vaccine. Additionally, Resident R118, who had type 2 diabetes mellitus and chronic kidney disease, received two doses of the PCV13 but was not offered the PCV20. The facility's policy, which follows CDC recommendations, was not followed, as the residents were not offered the PCV20 vaccine after receiving the PCV13, leading to a deficiency in the facility's immunization practices.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the survey were readily available for residents to view, which has the potential to affect all 206 residents residing in the facility. During a resident council meeting, seven attendees reported that they had never seen a book or binder containing the survey results. Observations confirmed that there was no folder or binder with the survey reports in common areas such as the lobby, library, dining hall, or theatre room. The facility administrator attempted to locate the binder with the survey results but was unable to find it, confirming the deficiency in making survey results accessible to residents.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers twice a week per its policy for two residents, R3 and R6, who were reviewed for showers. R6, diagnosed with multiple conditions including Parkinson's disease and chronic heart failure, was cognitively intact and dependent on staff for bathing. Despite being scheduled for baths every Tuesday and Friday, R6 reported only receiving baths once a week due to staff time constraints. Documentation showed R6 was marked as having refused or not applicable for several scheduled Friday baths, but there was no nursing progress note indicating R6 refused showers. R6 expressed a desire to move her bath schedule to Friday mornings to ensure consistency. Similarly, R3, with diagnoses including osteoarthritis and anxiety, required substantial assistance for bathing. R3 reported having to fight for showers as staff were often too busy, and there was no record of R3 refusing showers in the nursing progress notes. However, bathing documentation inaccurately recorded R3 as refusing showers on multiple occasions. R3 and her roommate both stated that the staff claimed they had no time or it was not R3's scheduled day for a shower, contradicting the facility's policy that residents should be offered showers twice weekly.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff remained with a resident until all medications were administered, as per facility policy. This deficiency was identified when medications were found at the bedside of a resident, R2, who was part of a sample of seven residents reviewed. The incident was reported on 8/25/24 when a family member observed medications at R2's bedside. R2 initially denied that the medications were hers, claiming she had already taken them. However, upon further questioning, R2 admitted she might have forgotten to take the medications provided earlier that morning. The medications included vitamins, supplements, and other typical morning medications, but no narcotics. The Minimum Data Set (MDS) indicated that R2 had moderately impaired cognition, which may have contributed to the incident. The Registered Nurse Supervisor, V4, confirmed that the medications found were R2's morning doses and should not have been left with the resident. The facility's policy, as outlined in the document 'Administering Oral Medications,' requires staff to remain with residents until all medications are taken. Despite this policy, the Registered Nurse, V5, who was responsible for administering the medications, insisted that she watched R2 take her medications that morning, contradicting the evidence found at the scene.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide personal care to dependent residents, specifically two residents with cognitive impairments. One resident, a [AGE] year-old female with moderate cognitive impairment, was found with a strong urine odor and a soaked, discolored incontinent brief. The LPN acknowledged that the resident had not been changed as required by the facility's guidelines, which mandate changing residents every two hours and as needed. The resident's care plan included interventions for the risk of impaired skin integrity, but these were not followed as observed on the date of the survey. Another resident, a [AGE] year-old female with mild cognitive impairment, reported that she was often not changed on time and could not recall being changed on the day of the observation. The LPN found this resident with a heavily soiled and discolored incontinent brief. Similar to the first case, the resident's care plan included interventions for the risk of impaired skin integrity, which were not adhered to. The Director of Nursing confirmed that incontinent care should be provided every two hours and as needed, as per the facility's policy revised in March 2020.
Improper Urinary Catheter Insertion Procedure
Penalty
Summary
The facility failed to ensure proper urinary catheter insertion procedures were followed, leading to potential cross-contamination. A nurse and a CNA were observed performing a straight catheterization on a resident without cleaning the left and right labia area and without using sterile gloves. The resident, a [AGE] year-old female with spina bifida, chronic idiopathic constipation, bladder dysfunction, and a history of urinary tract infections, had an order for straight urinary catheterization every four hours. The nurse admitted to not knowing the proper procedure for cleansing the labia and urethral meatus before catheter insertion. The Director of Nursing confirmed that the staff should follow the straight catheterization guidelines to avoid urinary tract infections. According to the facility's Urinary Straight Catheter policy, the labia and urethral meatus should be cleansed using separate cotton balls for each downward stroke, and the catheter should be handled with sterile gloves. The failure to adhere to these guidelines was observed and acknowledged by the staff involved, indicating a lapse in following established protocols for catheter care.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure Activities of Daily Living (ADL) assistance was provided for three residents who required extensive assistance. Resident 1 (R1) was admitted with diagnoses including Alzheimer's disease, dementia, heart failure, dermatitis, and malnutrition. R1's care plan indicated a need for total assistance with personal hygiene and dressing, and to be checked every two hours for incontinence. On April 8, 2024, R1 was found in bed with a saturated incontinence brief and wet sheets, indicating that incontinence care had not been provided in a timely manner. The dressing on R1's sacrum was also saturated, and there was a strong urine odor present. The CNA admitted it was the first time she had provided incontinence care to R1 that day, despite the care plan's requirements for frequent checks and assistance. Resident 2 (R2) and Resident 3 (R3) also experienced similar deficiencies in care. R2, with diagnoses including schizoaffective disorder, anxiety disorder, and bipolar disorder, was found with a saturated incontinence brief and wet sheets. The CNA confirmed it was the first time she had provided incontinence care to R2 that day. R3, diagnosed with Parkinson's disease, Alzheimer's disease, dementia, schizophrenia, and major depressive disorder, was found with a saturated incontinence brief and a strong urine odor. Documentation showed no incontinence care was provided to R3 prior to 11:20 AM. The facility's policy required incontinence care to be provided at least every two hours, but this was not adhered to for these residents, leading to the observed deficiencies.
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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 Norridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community First Medical Center | 1 mi | ★★★★★ | 0 | 0 |
| Alden Estates Of Northmoor | 2.1 mi | ★★★★★ | 5 | 0 |
| Pearl Of Montclare, The | 2.2 mi | ★★★★★ | 3 | 0 |
| Central Nursing Home | 2.4 mi | ★★★★★ | 10 | 0 |
| Norwood Crossing | 2.5 mi | ★★★★★ | 5 | 0 |
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