Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Norwood Crossing during CMS and state inspections, most recent first.
Failure to protect a resident from verbal and physical sexual abuse by a roommate who had a prior history of inappropriate sexual behavior toward another male resident. The abused resident, who had multiple physical and cognitive impairments, reported unwanted sexual comments and touching while in bed. Records and staff interviews showed the roommate had previously touched another male resident inappropriately in the dining area and had also been documented attempting similar behavior earlier, yet the other resident’s chart lacked documentation of the incident and did not identify him as at risk for abuse.
Failure to report an allegation of abuse: staff documented that one resident repeatedly touched another resident inappropriately in the common area, including toward the groin, and interviews confirmed the behavior was witnessed and stopped by staff. The affected resident indicated the touching was not consented to, and the DON/administrator had no reportable or investigation documentation for the incident. The facility’s abuse policy required investigation and reporting of any abuse allegation to the state agency within 24 hours.
Failure to investigate an abuse allegation involving two residents. Staff documented that one resident touched another male resident’s leg and groin area in the common area and continued the behavior multiple times, but no reportable investigation was found for the incident. Interviews confirmed the affected resident said the touch was not consented to, and staff reported prior inappropriate behavior by the same resident, including an incident with a male student and another resident in the dining room.
A resident with dementia, impaired mobility, and multiple fall risk factors was identified as high risk for falls, but no fall-prevention interventions were checked on the fall risk form despite a high score and a care plan noting fall risk. The resident, who often sat near the nurse’s station and was known by staff to frequently bend down to pick objects up from the floor, was left unsupervised in the hallway while an RN was passing medications elsewhere. The resident dropped an item, attempted to pick it up without assistance, fell, and sustained a displaced clavicle fracture. These events occurred despite facility policies requiring individualized assessment, documented interventions, and adequate supervision to prevent accidents.
The facility failed to maintain an effective pest control program, resulting in persistent gnats in hallways, resident rooms, and the kitchen. Surveyors and staff observed gnats flying in corridors, offices, and around nursing stations, as well as on window sills, beds, bedside tables, and near residents’ food. A visually impaired resident reported feeling gnats on her face and mouth, and another resident reported gnats on her table, food, and clothing. In the kitchen, cooks and the dining services director reported gnats flying throughout the area, and multiple dead gnats were seen on top of a large food container in the walk-in freezer. Maintenance staff acknowledged that gnats live in drains and identified a clogged, water-filled kitchen drain that was draining very slowly, while also noting that bug-repellent devices were not yet installed in the kitchen despite ongoing gnat activity.
A facility failed to adequately monitor fall-risk residents and failed to keep a soiled utility room securely locked. Six residents were observed unattended in a dining room/solarium, including residents in wheelchairs and geriatric chairs, while an RN briefly entered and left and no staff remained to monitor them. The DON and restorative nurse stated residents at risk for falls should be monitored at all times. The second-floor soiled utility room was also found unlocked, with sharps containers, needles, razors, disinfectant, biohazard waste, and an unsecured bio-hazard room inside.
Late Medication Administration for Multiple Residents: An RN had five residents whose 9:00 AM meds had not been given during med pass, and the RN stated the doses would be late because resident requests and assistance delayed administration. The DON stated meds are expected to be passed on time and that anything given more than one hour after the scheduled time is considered late. The affected residents had diagnoses including dementia, AFib, HTN, diabetes, CHF, and other chronic conditions, and were ordered medications such as Eliquis, Lasix, clopidogrel, gabapentin, metformin, nifedipine ER, and potassium chloride.
Medication carts and storage rooms contained multiple unlabeled or partially labeled meds and expired supplies. Surveyors found insulin products on the 2nd and 3rd floor carts without required open or expiration dates, along with OTC meds and vitamins lacking open and expiration dates, and expired IV-related supplies left in storage instead of being discarded. The DON stated insulin must be labeled with the date opened and expiration date, and expired syringes and supplies should be discarded.
Failure to use required PPE during incontinence care: A CNA provided incontinence care to a resident on enhanced barrier precautions while wearing gloves but no gown, despite posted instructions requiring gloves and gown for high-contact care. The CNA handled the resident’s soiled diaper, discarded it, and then retrieved a clean gown from the resident’s clean linen cart while still wearing the same soiled gloves, and acknowledged the potential for cross contamination when proper PPE and infection prevention protocols are not followed.
Failure to provide timely incontinence care: A cognitively intact resident who was dependent for toileting hygiene and toilet transfer was found sitting in bed and reported wanting to get up and dressed for a doctor’s appointment. When a CNA later entered the room, the resident’s brief and incontinent pad were saturated with urine, despite the care plan directing checks every 2 to 3 hours. The DON stated that residents with heavy incontinence should be checked at least every 2 hours.
Failure to provide timely 1:1 feeding assistance for a resident with dementia, severe protein-calorie malnutrition, and a pressure injury. The resident's lunch tray was left untouched while he remained in bed, and staff observed that he had not eaten even though lunch had arrived. A CNA said she was feeding another resident and then planned to assist, while the RN said the resident should eat when lunch arrives and that she had seen the tray but was not aware he needed help.
Air Mattress Pump Not Functioning Properly for At-Risk Resident: A resident at risk for pressure ulcers was observed in bed with an air loss mattress whose pump screen was dark, with no sound heard and the mattress appearing slightly flat and lumpy. Staff attempted to use the pump controls without success until a hose/tube was reinserted more tightly, after which the screen lit up and the pump could be heard running. The resident's care plan noted risk for skin breakdown due to impaired mobility, a pelvic fracture, and incontinence, and an active order for an air mattress was in place.
A facility failed to ensure proper medication storage and security, affecting residents on the 4th floor. A resident was found with medications at the bedside without a physician's order, and treatment carts were left unlocked and unattended. Staff acknowledged the carts should be locked when not in use, highlighting a lapse in adherence to facility policy.
The facility failed to accurately log refrigerator and freezer temperatures and check the dating and labeling of food items, with records showing future dates. This inaccuracy was acknowledged by the Director of Dietary Services, who noted the importance of proper documentation to prevent food spoilage and potential illness among the 104 residents receiving an oral diet.
A facility failed to treat a resident with dignity by placing handwritten signs in the resident's room to remind nurses about wound care. These signs, intended for staff, were visible in various locations and included specific instructions for wound dressing changes. The DON acknowledged that such postings violated confidentiality, although the facility's policy emphasizes dignity, respect, and privacy.
A resident with a venous stasis ulcer did not receive consistent wound care as ordered, due to a misunderstanding among nursing staff about treatment responsibilities. The resident's wound worsened over time, with documentation missing for several scheduled treatments.
A resident with multiple medical conditions and cognitive impairment, identified as a high fall risk, experienced an unwitnessed fall resulting in a lumbar fracture due to inadequate supervision. Despite being placed by the nurse's station for monitoring, the resident was left unsupervised when a CNA went on break, and the RN was occupied with other duties. The facility's fall prevention policy was not adequately followed, leading to the incident.
The facility failed to monitor and address significant weight loss for three residents, leading to a deficiency in nutritional care. One resident experienced a 15.7% weight decrease over six months, with inadequate monitoring and dietary assessment. Another resident had a severe weight loss of 6.28% in one month, with missing monthly weights and no dietary intervention. A third resident lost 12 pounds over two months, with missing weights and no timely dietary assessment. The facility's policies for weight monitoring and nutritional assessment were not followed, resulting in unaddressed nutritional needs.
The facility failed to properly label and store food, with items found without dates in the refrigerator and freezer, and expired or undated items in dry storage. Additionally, food was improperly stored near cleaning products in medication rooms, violating storage policies. This affected 106 residents receiving an oral diet.
The facility failed to maintain enhanced barrier precautions and educate visitors on contact isolation precautions, impacting infection control. Staff entered rooms without proper hand hygiene and PPE, and suction equipment was mishandled. Policies on infection prevention were outdated, contributing to these deficiencies.
The facility failed to properly use low air loss mattresses for residents at risk of pressure ulcers. Two residents had incorrect weight settings on their mattresses, and another resident's mattress machine was turned off. Additionally, improper linens were used on the mattresses, contrary to facility policy, potentially impeding airflow and pressure relief.
The facility failed to provide proper respiratory care and equipment management for several residents. One resident with COPD had disconnected and kinked oxygen tubing, resulting in inadequate oxygen delivery. Another resident adjusted their oxygen flow independently, deviating from the prescribed amount. Additionally, respiratory supplies were improperly stored and not labeled according to facility policy, as observed during a survey.
The facility failed to properly label and manage medications, including expired and discontinued drugs, as observed in medication carts. An open bottle of Multivitamin with a past 'Best By' date and loose tablets were found, along with a blister pack of Alprazolam with broken seals for a resident whose medication had been discontinued. Additionally, a bottle of Audiologist Choice Wax Softener was improperly stored. Facility policies on medication storage and disposal were not followed.
A resident with multiple health conditions, including COPD and heart failure, was self-administering medications without a completed assessment, physician's order, or care plan. The resident was observed with inhalers at the bedside, and staff acknowledged the lack of a formal assessment, contrary to facility policy requiring evaluation of the resident's capability to self-administer medications.
The facility failed to ensure that a resident's treatment preferences, as documented on the POLST form, were accurately reflected in the care plan. The POLST indicated a DNR order and selective treatment, but the facility's practice did not differentiate between selective or comfort care in the DNR order. Interviews revealed a lack of clarity and consistency in handling POLST forms, with staff relying on nurses to read the document directly and no process for entering specific orders from Section B into the electronic health record.
A resident's care plan was not updated to reflect a physician's order for one-to-one meal assistance, resulting in the resident eating alone without staff help. Despite the order being documented after a hospital discharge, staff were unaware of the requirement, and the facility's policy on meal assistance was not followed.
A facility failed to provide appropriate restorative care for a resident with hand contractures, as the required splints were not applied, and quarterly restorative assessments were not completed. The resident, who is on active and passive range of motion programs, had not been assessed since August 2023, and there was no documentation of progress in restorative services. The facility's policy requires restorative care to prevent deterioration, but this was not followed.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to ensure a resident remained free from verbal and physical sexual abuse by another resident who had a prior history of inappropriate sexual behavior toward a different resident. The abused resident was an older male with diagnoses including difficulty walking, muscle atrophy, weakness, need for assistance with personal care, blindness, symptoms and signs involving cognitive functions and awareness, and major depressive disorder. He reported that his roommate made inappropriate sexual comments and touched his upper leg and attempted to touch his genital area while he was in bed, and he told the roommate he did not want that type of interaction. The roommate involved was an older male with diagnoses including peripheral autonomic neuropathy, hypertension, anemia, and major depressive disorder, and records showed he had a behavioral concern for inappropriately touching other male residents before the incident. Staff interviews described that he had previously touched another male resident in the dining room, including touching the resident’s upper thigh and moving his hand toward the groin area, and staff had to separate him from that resident more than once. A progress note also documented that he had attempted to touch another male resident inappropriately in the common area on an earlier date, with staff observing him reaching toward the resident’s leg and groin area and intervening after the resident showed distress. The abused resident’s record documented the incident and his report of unwanted sexual comments and touching, and his trauma informed consent later reflected that a roommate had made sexually inappropriate comments and touched his leg. The other resident who was touched did not have a trauma informed consent assessment in the chart, and his care plan did not identify him as at risk for abuse. Interviews showed staff were aware of the roommate’s inappropriate behavior and had monitored and redirected him, but the report also showed that the earlier incident involving the other resident was not documented in that resident’s progress notes and that the facility did not have a record of a trauma informed consent assessment for him.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency. The deficiency involved two of three residents reviewed for abuse in the sample of five. Records showed that on 12/5/25, staff documented that one resident attempted to touch another male resident inappropriately while both were in the common area. The note stated staff observed the resident reaching toward the other resident’s leg and groin area, intervened because of the other resident’s distress, and notified the administrator, POA, physician, and supervisor. Interviews confirmed the incident involved repeated inappropriate touching toward another resident. One resident, who had diagnoses including hemiplegia following cerebral infarction affecting his dominant side and aphasia following cerebral infarction, was interviewed and indicated that the other resident touched toward his groin area without his consent. A registered nurse stated she witnessed the resident touching the other resident’s upper thigh and moving his hand into the groin area, and that the other resident waved and called out for staff attention. The nurse also stated the resident attempted the behavior multiple times and was moved away each time. The administrator stated she had no knowledge of an incident involving the resident touching a nursing student inappropriately, and when the surveyor reviewed the resident’s progress note, she said it sounded like it should have been investigated. No reportable or investigation documentation for the incident involving the two residents was provided when requested. The facility’s abuse policy stated that any incident or allegation involving abuse, neglect, or misappropriation would result in an abuse investigation and that external reporting of potential abuse would be made to the Department of Public Health as soon as possible within 24 hours.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident after a prior incident was documented in another resident’s progress note. The note stated that staff observed one resident reaching toward another male resident’s leg and groin area in the common area, that the resident continued the behavior multiple times, and that the administrator, POA, physician, and supervisor were notified. However, no reportable investigation or documentation was provided for the incident involving the two residents, and the facility’s records for the resident who was touched contained no documentation of the event. During interview, the resident who was touched indicated that another man had touched toward his groin area, that he did not consent, and that the incident happened one time. Staff interviews confirmed there had been multiple incidents involving the resident who initiated the behavior, including reports that he had touched a male student and had been inappropriate with another resident in the dining room. The administrator stated the incident should have been investigated and that the purpose of an investigation is to determine the root cause of the inappropriate behavior, but no investigation for the resident-to-resident allegation was available.
Failure to Supervise High-Risk Resident and Implement Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement fall-prevention interventions for a resident identified as high risk for falls, resulting in a fall with injury. The resident had multiple diagnoses including epilepsy, muscle weakness, difficulty walking, lack of coordination, muscle wasting and atrophy, and dementia, with a BIMS score of 11 indicating moderately impaired cognition. A fall risk data collection form dated 01/16/26 showed a score of 16, designating the resident as high risk for falls and instructing that interventions be promptly implemented when the score is 10 or more; however, the form contained no checked interventions. The resident’s care plan documented that the resident was at risk for falls due to impaired mobility, history of right hip fracture with hemiarthroplasty, glaucoma, and gait/balance problems, and referenced the fall risk assessment, but did not reflect specific interventions from the fall risk form. On the date of the incident, the resident was found lying on the floor on her back in front of the nurse’s station with a bump on the back of the head and complaints of left shoulder pain, and was later diagnosed with a displaced fracture of the shaft of the left clavicle. The resident reported that she had been in the hallway alone, dropped an object, attempted to pick it up, and then fell. The RN assigned to the resident stated she did not witness the fall and was down the hall passing medications at the time, while the CNA reported that the resident typically sat at the nurse’s station most of the day, was a fall risk, needed constant observation, and would initiate activities without communicating needs. The NP stated the resident should have assistance when picking up objects from the floor and should be supervised because staff were aware the resident frequently tried to pick things up from the floor. The ADON confirmed that a fall risk score of 16 indicated high risk, acknowledged that interventions should have been completed on the fall risk form, and stated that a high-risk resident known to bend down to pick things up should not be left unsupervised in the hallway. These actions and inactions were inconsistent with the facility’s written policies on safety, supervision, and fall prevention, which require individualized assessment, implementation, communication, and documentation of interventions, and provision of necessary supervision to prevent accidents.
Ongoing Gnat Infestation in Resident Areas and Kitchen Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing gnat activity in resident care areas, hallways, and food service locations. Upon entering the facility, a surveyor observed gnats flying in the hallway and had to swat them away from her face. Staff interviews revealed that gnats had been seen in an MDS coordinator’s second-floor office, around nursing stations, and in residents’ rooms, including on window sills, beds, bedside tables, and near residents’ food. A housekeeper reported that gnats had previously been observed flying throughout the facility and that dead gnats were routinely cleaned from rooms and windows. One resident, who is visually impaired, reported feeling gnats hitting her skin and face and touching her mouth, while another resident reported gnats on her bedside table, near her food, and on her clothes, which she tried to swat away. In the kitchen, multiple staff members, including cooks and the dining services director, reported seeing gnats flying “everywhere” and noted that gnats can contaminate food items and spread disease. During a tour of the walk-in freezer with the dining services director, multiple dead gnats were observed on top of a large pickle container. Maintenance staff acknowledged that gnats live in drains and identified a clogged kitchen drain in the steamer/kettle area that was full of water and draining very slowly; a maintenance technician reported working for an hour to rod the drain without success. Although maintenance reported that an exterminator comes weekly and bug-repellent machines are used in hallways, there were no such machines yet in the kitchen, and staff across multiple floors confirmed that gnats continued to be present throughout the facility, with particular persistence on the second and third floors.
Unsupervised fall-risk residents and unsecured soiled utility room
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for residents at risk for falls. On 07/22/2025 at 10:37 AM, six residents were observed sitting unsupervised and unattended inside the fourth-floor dining room/solarium, including residents in wheelchairs and geriatric chairs, with seat pad alarms present for three of them. At 10:38 AM, an RN entered the dining room to administer medications and left at 10:39 AM, leaving the residents unattended again until two LEAs entered at 10:42 AM to conduct activities with them. The Restorative Nurse/Fall Coordinator stated that all residents in the facility are at risk for falls, that seat pad alarms only alert staff to positional movement and do not prevent falls, and that there should be someone monitoring the dining room at all times, especially for residents at risk for falls. The RN stated there is supposed to be someone inside the dining room monitoring residents at all times, that CNAs are not assigned designated times to monitor the dining room, and that CNAs take turns going in and out to check on residents. She also stated she did not know why no staff member was monitoring the residents when she arrived previously and that she did not assign any CNA to monitor the dining room after being made aware that fall risk residents were unsupervised and unattended. The facility policy titled Fall Protocol and Prevention states that residents assessed at risk for falls will be monitored and that all departments are encouraged to assist in the prevention of accidents and falls. The facility also failed to ensure a dependable locking mechanism on the second-floor soiled utility room door. On 7/23/25 at 1:45 PM, the door was observed not locked or secured, and the five-button locking system could be opened without a code. Inside were four sharps containers with visible syringes and needles, razors, a one-gallon bottle labeled disinfectant, a rolling trash can with trash, a hopper with standing water, a toilet plunger, approximately nine glass vases, and a smaller room labeled bio-hazard that had no lock. Inside the smaller room were approximately twelve red trash bins labeled only for isolation trash and two filled sharps containers. The RN and DON stated the room should be closed and locked, and the DON stated the room stored waste products, biohazard/infectious material, and sharps containers for disposal.
Late Medication Administration for Multiple Residents
Penalty
Summary
Facility failed to provide medications in compliance with standards of professional practice for five residents during medication administration. On 07/22/2025 at 10:11 AM, the RN administering medications had five residents—R19, R32, R39, R58, and R77—who had not yet received their scheduled 9:00 AM medications. The report states that scheduled medications may be given one hour before or one hour after the scheduled time, and anything more than one hour past the scheduled time is considered late. On 07/24/2025 at 10:12 AM, the RN stated that the five residents remained to receive medications and that they would be late because the RN had been assisting residents with requests, which contributed to the delay. R19 had diagnoses including dementia with behavioral disturbance, hyperlipidemia, generalized anxiety disorder, and urinary tract infection, and was scheduled to receive aspirin, azelastine nasal spray, cephalexin, and Namenda at 9:00 AM. R32 had diagnoses including atrial fibrillation and dementia and was scheduled to receive Eliquis and Lasix at 9:00 AM. R39 had diagnoses including atrial fibrillation, insomnia, hypertension, muscle weakness, and lack of coordination and was scheduled to receive Eliquis and ferrous sulfate at 9:00 AM. R58 had diagnoses including sequelae of cerebrovascular disease, pneumonia, upper respiratory infection, and breast cancer and was scheduled to receive buspirone, clopidogrel, gabapentin, and hydralazine at 9:00 AM. R77 had diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, chronic systolic heart failure, and osteoarthritis and was scheduled to receive Jardiance, metformin, nifedipine ER, and potassium chloride at 9:00 AM. The DON stated that medications are expected to be passed on time and that anything given more than one hour past the scheduled time is considered late.
Medication Labeling and Expired Supply Storage Deficiencies
Penalty
Summary
The facility failed to follow standards of practice for medication labeling and storage by leaving multiple medications on the 2nd and 3rd floor medication carts without required open dates and expiration dates, and by keeping expired medical supplies in storage. During survey observations, the surveyor found an opened Humalog insulin vial on the 2nd floor odd side cart with an open date but no marked expiration date, along with several bottles of over-the-counter medications and vitamins, including simethicone, vitamin B-12, vitamin D, ibuprofen, melatonin, acetaminophen, and zinc, that had no marked date when opened and no marked expiration date. On the 2nd floor even side cart, the surveyor found additional bottles of vitamin D, B-12, and a Novolin insulin flex pen without open or expiration dates. On the 3rd floor odd side cart, the surveyor found R53's Novolin 70/30 flex pen and R102's Lantus insulin vial and insulin lispro vial, as well as R5's Lantus vial, each marked with an open date but not marked with an expiration date. In the medication storage rooms, the surveyor found expired supplies that had not been discarded, including six IV safety catheters labeled with an expiration date of 11-29-2021, eight female luer lock caps with an expiration date of [DATE], and one secondary medication set IV tubing labeled with an expiration date of 02/2025. The DON stated that insulin must be labeled with the date opened and the date it expires, and that expired syringes and supplies should be discarded.
Failure to Use Required PPE During Incontinence Care
Penalty
Summary
The facility failed to practice infection control and prevention and failed to ensure appropriate PPE was worn by staff caring for a resident on enhanced barrier precautions. A sign posted on the resident’s door stated that staff must clean their hands before entering and when leaving the room and must wear gloves and a gown for high-contact resident care activities, including dressing, bathing/showering, transferring, changing linens, providing hygiene, and changing briefs or assisting with toileting. During observation, a CNA was inside the resident’s room providing incontinence care and changing the resident’s diaper while wearing gloves but no gown. When questioned, the CNA stated he forgot to put on a gown because he got busy. The CNA was observed picking up the resident’s soiled diaper from the floor while wearing gloves, stating he placed a clean gown inside the resident’s clean linen cart for himself. He then threw the soiled diaper in the trash and walked outside the room to retrieve a clean gown from the resident’s clean linen cart while still wearing the same soiled gloves. When asked about hand hygiene and infection control when handling clean and soiled items, the CNA stated there was potential for cross contamination if the appropriate PPE and infection prevention protocols were not followed. The facility policy dated 04/30/2025 stated the facility would establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of disease and infection.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide ADL care for a dependent resident who required assistance with bladder and bowel incontinence. The resident’s face sheet documented diagnoses including acute respiratory failure with hypoxia, COPD, need for assistance with personal care, lack of coordination, and muscle weakness. The MDS dated 7/16/2025 documented a BIMS score of 15, indicating the resident was cognitively intact, and showed the resident was dependent for toileting hygiene and toilet transfer, requiring the assistance of 2 or more helpers. The resident’s bowel and bladder incontinence care plan, initiated/revised 2/20/2024, directed staff to check the resident every 2 to 3 hours for incontinence and assist with toileting if needed. On 7/22/2025 at 10:50 AM, the resident was observed awake and alert sitting up in bed and stated that there was a lack of communication, that staff had been told the resident wanted to get up and get dressed for a doctor’s appointment, and that the resident might already be wet. At 11:20 AM, a CNA entered the room and stated she was going to change the resident because the resident had an appointment that day. The resident’s brief had a blue stripe indicating wetness and was saturated with urine in the front and back, and the incontinent pad was wet with urine. The CNA stated she had checked the resident at 7:00 AM and that this was the first time she was changing the resident. The DON stated that prompt incontinence care is important to maintain skin integrity and keep the resident clean and dry, and that residents with heavy incontinence should be checked at least every two hours.
Failure to Provide Timely 1:1 Feeding Assistance
Penalty
Summary
The facility failed to provide timely 1:1 feeding assistance for a resident who required meal assistance. R2 was observed lying in bed awake with the head of the bed slightly elevated, and when asked in Spanish if he wanted to eat, he said yes; when asked if he had eaten, he said no. His lunch tray was observed untouched on the overhead bedside table at 12:31 PM and remained untouched at 12:43 PM. At 12:46 PM, a CNA entered the room and stated she would change R2's incontinence brief and then provide feeding assistance, explaining that she had been feeding another resident and did not know lunch time, though she thought it was probably 12:00 PM. She stated R2 should not have waited that long for lunch and that she had not asked any staff to assist her with feeding him. The RN stated lunch time was 12:00 PM, that R2 should eat when lunch arrives despite being a feeder, and that she had seen the lunch tray during rounds but was not aware he needed to be fed. The resident's record showed diagnoses including unspecified dementia, severe protein-calorie malnutrition, and pressure-induced deep tissue damage of the sacral region, with a care plan and physician order for 1:1 feeding assistance and a nursing assignment sheet documenting meal assistance.
Air Mattress Pump Not Functioning Properly for At-Risk Resident
Penalty
Summary
Failure to provide appropriate pressure ulcer care occurred when the facility did not ensure a pressure relieving device was functioning properly for one resident who was at risk for pressure ulcers. R20 was observed lying in bed asleep and in no apparent distress, with an air loss mattress and pump in place. At the time of observation, the pump display screen was dark, no items were displayed, and no sound was heard from the pump. R20's mattress appeared and felt slightly flat and lumpy. During the observation, V15 attempted to press the lock button and on/off button on the pump, but nothing appeared on the screen. V6 then pressed several buttons and found the screen still did not appear until a hose/tube was pulled out and reinserted more tightly, after which the pump screen lit up and sound was heard. The resident's care plan documented risk for pressure ulcer/skin breakdown due to impaired mobility, right pelvic fracture, and incontinence, and the active physician order set included an air mattress dated 02/17/2023. The manufacturer manual provided by the facility stated that if the controller is inoperable, the mattress may feel lumpy and the solution is to make sure the controller is plugged in and turned on.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage for a resident and secure treatment carts, which could potentially affect all residents on the 4th floor. During an observation, a resident was found with a bottle of Fluocinonide topical solution and a tube of Econazole nitrate cream left at the bedside without a physician's order to do so. The Assistant Director of Nursing (ADON) confirmed that no medication should be left at the bedside without a physician's order, and the Electronic Physician Order (EPO) for the resident did not include such an order. The Registered Nurse (RN) assigned to the resident was unsure about the professional standards for medication storage, indicating a lack of knowledge and adherence to facility policy. Additionally, the facility failed to ensure that treatment carts were locked when not in use or when not in the visual proximity of a nurse. On multiple occasions, treatment carts were found unlocked and unattended on different floors, with no licensed nurse or staff present. The Director of Nursing (DON) and other staff members acknowledged that the carts should always be locked when not in use, as per facility policy. This oversight in securing medication carts poses a risk to the safety and security of medications within the facility.
Improper Logging of Food Storage Temperatures and Expiration Checks
Penalty
Summary
The facility failed to properly log refrigerator and freezer temperatures in the kitchen, as well as the checking of the dating and labeling of food items and removal of expired items. During an observation with the Director of Dietary Services, it was noted that temperature logs for the walk-in freezer, ice cream freezer, and two refrigerators were documented for future dates, indicating inaccurate record-keeping. Additionally, the facility's dietary audit form showed that the checking of food items for dating and labeling, as well as the removal of expired items, was also documented for a future date. The Director of Dietary Services acknowledged the errors, stating that the documentation should be done during the AM and PM shifts and that the mistake was likely due to confusion over the date. The facility's policy requires that refrigerator temperatures be maintained between 35 to 39 degrees Fahrenheit and checked at least twice daily, while freezer temperatures should keep food frozen solid and also be checked twice daily. The failure to adhere to these procedures has the potential to affect all 104 residents receiving an oral diet in the facility, as improper food storage can lead to food spoilage and potential illness among residents.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified manner, as evidenced by the placement of handwritten signs in the resident's room. A registered nurse placed these signs to remind other nurses to change the resident's wound dressing, which were observed taped to the walls in various locations of the resident's room. The signs included instructions for the morning shift nurse to perform wound care on specific days and a note for the foot doctor not to handle the resident's dressing or wound. The Director of Nursing acknowledged that such instructions should not be posted on resident walls due to confidentiality concerns, although the facility's policy emphasizes treating residents with dignity and respect and maintaining privacy and confidentiality of personal and medical records.
Failure to Provide Consistent Wound Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote wound healing for a resident with a venous stasis ulcer. The resident, who had intact cognition and multiple medical diagnoses including peripheral vascular disease and chronic ulcer, had specific physician orders for wound care that were not consistently documented as completed. The Treatment Administration Record showed missing documentation for wound care on several occasions, indicating that the care may not have been performed as required. Interviews revealed that there was a misunderstanding among the nursing staff regarding the responsibility for changing the resident's wound dressings. The Director of Nursing acknowledged that the nurses mistakenly believed the podiatrist was responsible for the wound care on certain days, leading to missed treatments. This oversight resulted in the resident's wound worsening over time, as evidenced by the increase in wound size from December to February.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as a high fall risk, resulting in an unwitnessed fall and a lumbar fracture. The resident, a 69-year-old with multiple medical diagnoses including malignant neoplasm of the right main bronchus, secondary malignant neoplasm of the brain, and severe protein-calorie malnutrition, was cognitively impaired and required maximum assistance with transfers. Despite being placed by the nurse's station for closer monitoring, the resident experienced a fall when left unsupervised. On the morning of the incident, the resident was noted to be anxious and attempting to get out of bed. The registered nurse and a certified nurse assistant redirected the resident multiple times and eventually transferred her to a wheelchair for closer supervision at the nurse's station. However, when the CNA went on lunch break, the registered nurse, who was responsible for monitoring the resident, was occupied with other duties, including medication administration and blood sugar checks, and did not ensure continuous supervision. The director of nursing, upon investigation, noted that the registered nurse should have requested assistance to monitor the resident when the CNA went on break. The facility's fall prevention policy mandates close observation of residents assessed at risk for falls, which was not adequately followed in this case. The lack of supervision led to the resident's fall and subsequent injury, highlighting a deficiency in the facility's adherence to its fall prevention protocols.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to obtain monthly weights and address significant weight loss for three residents, leading to a deficiency in maintaining adequate nutrition and hydration. Resident R17 experienced a 15.7% decrease in weight over six months, with a notable 7.85% weight loss in one month. Despite the facility's policy requiring monthly and weekly weights for residents at risk, R17's weight loss was not adequately monitored or addressed. The Registered Dietitian (V12) acknowledged that the weight loss should have triggered a dietary assessment, but due to staffing changes and lack of documentation, R17's nutritional needs were not met. Resident R66 also experienced significant weight fluctuations, with a severe weight loss of 6.28% from January to February. The facility failed to obtain monthly weights for March and April, and no dietary assessment was conducted to address the weight loss. The Registered Dietitian (V12) was not informed of R66's weight loss, and there was no documentation explaining the lack of weight monitoring. The Director of Nursing (V2) stated that Certified Nurse Aides are responsible for weighing residents monthly, but this protocol was not followed for R66. Resident R61's records showed a 12-pound weight loss from December to February, with missing weights for January and March. The weight loss was not recognized or addressed by the facility, and no dietary assessment was conducted until May. The Regional Nutrition Director (V13) confirmed that the weight loss should have been addressed earlier, but there was no documentation or intervention in place. The facility's failure to monitor and address significant weight changes for these residents highlights a deficiency in their nutritional care practices.
Improper Food Storage and Labeling in Facility
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, which could potentially affect 106 residents receiving an oral diet. During an inspection, several food items in the walk-in refrigerator and freezer were found without proper labeling or dates, including egg salad, breadsticks, French fries, corn on the cob, pepperoni, shrimp, and a personal pan pizza. Additionally, in the dry storage room, items such as chocolate cake frosting and various seasonings were either expired or lacked proper dating. The Food Service Director acknowledged these issues, stating that all food items should be covered, dated, and labeled to prevent contamination and foodborne illness. Further inspection revealed improper storage of food items in medication rooms. On the fourth floor, applesauce containers were found stored next to disinfecting spray, and on the second floor, bottles of wine were stored next to bleach sanitation wipes. The wine was intended for a resident's consumption as per their order summary. The Director of Nursing confirmed that food should not be stored in medication rooms, especially near cleaning products, as it violates the facility's storage practices and policies.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to maintain enhanced barrier precautions for three residents, failed to educate visitors on contact isolation precautions for one resident, and failed to maintain suction equipment within professional standards of practice for one resident. Additionally, the facility did not annually update policies related to infection prevention and control. These deficiencies were observed during a survey, where staff members entered rooms with enhanced barrier precautions without performing hand hygiene and failed to wear appropriate personal protective equipment (PPE) during high-contact resident care activities. One resident had an enhanced barrier precautions sign on the door, but a registered nurse entered the room without performing hand hygiene and handled suction equipment improperly. The suction catheter was found open and possibly contaminated, which contradicts the facility's infection control policies. Another resident's care plan required the use of gowns and gloves for high-contact activities, such as administering medications via a gastrostomy tube, but the nurse only donned gloves, neglecting to wear a gown. A resident on contact isolation for ESBL in urine had signage indicating the need for PPE, but a family member entered the room without donning the required gown and gloves. The family member was not informed of the need for PPE until after entering the room, despite visiting daily. The facility's policies on hand hygiene and infection control were outdated, with the last updates occurring several years prior, indicating a lack of adherence to current professional standards and practices.
Failure to Ensure Proper Use of Low Air Loss Mattresses
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the use of low air loss mattresses for residents at risk of developing pressure ulcers. Specifically, the facility did not ensure that the weight control settings on the low air loss mattresses were correctly adjusted for two residents. One resident's mattress was set between 287 and 375 pounds, while the resident's actual weight was documented as 134 pounds. Additionally, another resident's low air loss machine was found to be turned off, which was contrary to the facility's policy that requires the machine to be on at all times when the resident is in bed. Furthermore, the facility did not follow its policy on the appropriate use of linens on low air loss mattresses. Two residents were observed lying on a flat sheet and a non-disposable incontinence pad, which is against the facility's policy that only a thin cotton flat sheet or a disposable incontinence pad should be used to avoid disrupting the airflow of the mattress. These deficiencies were identified through observations, interviews, and record reviews, highlighting a failure to provide adequate pressure ulcer care and prevention for residents at risk.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to ensure proper respiratory care for several residents, as observed during a survey. One resident with a history of Chronic Obstructive Pulmonary Disease (COPD) and other health issues was found with disconnected and kinked oxygen tubing, which was not delivering the prescribed 2 liters of oxygen. The resident's oxygen saturation was measured at 90%, below the target of greater than 92%, indicating inadequate oxygen delivery. The resident admitted to pulling the tubing when getting out of bed, and the nurse confirmed the tubing was not properly connected. Another resident, also with COPD and other cardiac conditions, was observed using oxygen at 3.5 liters per minute instead of the prescribed 4 liters. The resident adjusted the oxygen flow independently, citing shortness of breath during therapy sessions. The nurse acknowledged the resident's alertness and orientation but did not ensure the oxygen was set according to the physician's order. Additionally, the oxygen supplies were not labeled and dated as per facility policy. Further observations revealed improper storage and labeling of respiratory supplies for other residents. One resident's oxygen tubing was found undated on a nightstand, and another's suction machine was improperly placed on the floor with an uncovered oral suction tube. The facility's policy requires weekly changes and proper storage of oxygen and suction equipment to prevent contamination, which was not adhered to, as confirmed by the Director of Nursing.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly label and manage medications, as observed during a survey of the fourth floor, odd side, medication cart. An open bottle of Multivitamin with Minerals was found with a past 'Best By' date, and two unknown, loose green tablets were discovered out of their original packaging. Additionally, a blister pack of Alprazolam 0.25 mg for a resident had broken seals, and the nurse was unsure of the contents and the facility protocol for handling such medications. The resident's records indicated that the Alprazolam had been discontinued, yet it remained in the medication cart. Further issues were identified on the second floor, even side, medication cart, where a bottle of Audiologist Choice Wax Softener was found with a broken seal, not in its original packaging, and without a resident name or open date. The Director of Nursing stated that nurses are responsible for their medication carts, and night shift nurses should ensure medications are up to date and not expired. The facility's policies require medications to be stored in their original packaging and discontinued or outdated medications to be returned or destroyed, which was not adhered to in these instances.
Failure to Assess Resident's Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R54, who was self-administering medications, had the necessary self-administration of medications assessment, a physician's order, and a care plan completed. R54 has multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Atrial Fibrillation, among others. The resident was observed with an albuterol inhaler inside a tissue box at the bedside and Spiriva in the top drawer of the bedside table. R54 stated that they self-administered Spiriva once a day and used the albuterol inhaler every 4-6 hours as needed for shortness of breath. During the survey, it was noted that R54 did not have an assessment for medication self-administration, despite being alert and oriented. The Agency Registered Nurse, V7, acknowledged awareness of R54's possession and use of the inhalers but confirmed the absence of a formal assessment. The Director of Nursing, V2, later confirmed that an assessment should have been conducted to evaluate R54's capability to self-administer medications, as medications at the bedside pose a potential for error. The facility's policy on self-administration of drugs requires an assessment of the resident's mental and physical abilities to determine their capability to self-administer medications. This includes evaluating the resident's ability to read and understand medication labels, comprehend the purpose and proper dosage, and recognize risks and adverse consequences. The policy also mandates documentation of these assessments in the medical record, which was not completed for R54 prior to the surveyor's observation.
Failure to Honor Resident's POLST Preferences
Penalty
Summary
The facility failed to ensure that the provider order and care plan accurately reflected a resident's wishes as documented on the Provider Order for Life-Sustaining Treatment (POLST) form. Specifically, for one resident, the POLST form indicated a Do Not Resuscitate (DNR) order in Section A and selective treatment in Section B, which included medical interventions such as IV fluids and medications but not intubation. However, the facility's practice did not differentiate between selective or comfort care in the DNR order, leading to a misunderstanding of the resident's treatment preferences. Interviews with facility staff revealed a lack of clarity and consistency in handling POLST forms. The Director of Social Services stated that the facility does not document full treatment, selective treatment, or comfort measures, and instead relies on nurses to read the POLST document directly. The Director of Nursing and the Infection Prevention Nurse acknowledged that the facility does not have a process for entering specific orders from Section B of the POLST into the electronic health record, and there was confusion about the term "partial code." This lack of a clear process and understanding among staff contributed to the deficiency in honoring the resident's treatment preferences as outlined in the POLST form.
Failure to Provide One-to-One Meal Assistance
Penalty
Summary
The facility failed to follow physician orders and update a resident's care plan, specifically for a resident identified as R14. R14's care plan did not reflect the physician's order for one-to-one assistance during meals, which was documented as necessary due to the resident's medical conditions, including cellulitis, blindness, chronic kidney disease, and significant weight loss. Despite the order for one-to-one assistance, observations revealed that R14 ate meals alone without staff assistance on multiple occasions. Interviews with staff, including certified nurse aides and nurses, confirmed that R14 did not receive the required one-to-one assistance during meals. The deficiency was further highlighted by the lack of awareness among staff regarding the necessity of the one-to-one assistance order. Nurses V16 and V10 were unsure why R14 required such assistance, and V29 stated that the order was entered after R14 returned from the hospital, based on hospital discharge papers or verbal reports. The Director of Nursing confirmed that the hospital had reported R14 needed one-to-one feeding assistance due to weakness. The facility's policy on assisting residents with meals, which includes sitting with the resident and preparing food, was not followed, leading to the deficiency in care for R14.
Failure to Provide Appropriate Restorative Care for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as R61, to maintain or improve their range of motion. During an observation, it was noted that R61, who has contractures in both hands, was not wearing the required assistive devices or splints. Interviews with the Wound Care Nurse/Restorative Nurse Supervisor revealed that R61 is on active and passive range of motion restorative programs and should have a splint for the contracted hand daily, except during incontinence care or bathing. However, the nurse was unsure which hand required the splint and admitted that the facility had been without a full-time restorative nurse for some time. Further review of R61's electronic health records showed that the last restorative assessment was completed in August 2023, and there was no documentation detailing R61's progress or lack of progress in restorative services. The MDS Coordinator confirmed that R61 has physical limitations with their hands and is on restorative programs as outlined in the care plan. The facility's restorative policy emphasizes the importance of integrating restorative care approaches to prevent deterioration or maintain a resident's functional level, but this was not adhered to in R61's case.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,610 citations issued within 25 miles in the last 12 months — including the 29 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alden Estates Of Northmoor | 0.6 mi | ★★★★★ | 5 | 0 |
| Ascension Resurrection Life | 0.6 mi | ★★★★★ | 14 | 0 |
| Celebrate Senior Living Niles | 1.2 mi | ★★★★★ | 1 | 0 |
| Citadel At Saint Benedict | 1.5 mi | ★★★★★ | 0 | 0 |
| Elevate Care North Branch | 1.5 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.