Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Norris Square during CMS and state inspections, most recent first.
Delayed Call Light Response: Residents filed grievances about prolonged call light waits, including one cognitively intact resident with weakness, gait impairment, and toileting assistance needs who reported waiting 45 minutes for help and was observed waiting while staff passed by or assisted others. Another cognitively intact resident reported repeated 45-60 minute waits to get out of bed and morning accidents, and a third resident’s wife reported chronic delays. Call light logs showed repeated response times ranging from minutes to over an hour, and the administrator acknowledged the problem remained ongoing.
A resident who used a wheelchair and needed assistance with dressing had a foot plate with leftover food, dried liquid, and dirt observed over multiple checks. The resident said he did not know who was supposed to clean it and did not remember it ever being cleaned. Staff said wheelchairs were cleaned on the resident’s laundry day, but there was no documentation to verify cleaning had been completed, and the DON could not confirm when the wheelchair was last cleaned.
Failure to assess trauma history and provide trauma-informed care planning. A resident with PTSD, depression, anxiety, bipolar disorder, and mild cognitive impairment had no individualized trauma-informed care plan or identified triggers in the care plan or EHR. Staff stated they did not know the resident’s trauma history or triggers, while observations showed the resident repeatedly calling out for staff to sit with him and assist during meals. The DON and administrator confirmed the PTSD diagnosis and that the resident’s trauma was related to the unexpected suicide death of his brother.
A resident's wheelchair was observed to be dirty with dried food and liquids over several days, despite the facility's policy for maintaining cleanliness. Staff interviews confirmed that wheelchairs were to be cleaned weekly and as needed, but the resident's wheelchair remained unclean, indicating a lapse in adherence to the policy.
A resident with respiratory needs did not receive proper oxygen therapy due to staff failing to check and maintain oxygen levels in the portable tank and concentrator. The resident, diagnosed with respiratory failure, COPD, and CHF, was observed with an empty portable tank and without a nasal cannula, indicating a lack of oxygen flow. Staff did not adhere to facility policies requiring regular checks and proper storage of oxygen equipment.
Delayed Call Light Response
Penalty
Summary
The facility failed to develop interventions to ensure residents’ call lights were answered in a timely manner for residents who filed grievances about long call light response times. One resident was cognitively intact, had generalized muscle weakness and abnormal gait/mobility, required substantial assistance with toileting hygiene and transfers, and had care plan interventions to keep the call light within reach and answer it promptly. The resident also had frequent bladder and bowel incontinence, used an incontinence product, and had a toileting schedule for assistance upon rising, before and after meals, and before sleep. During interview and observation, the resident stated she often waited a long time for staff to answer her call light and reported waiting 45 minutes to get ready for the day. Continuous observation showed the resident’s call light remained on for an extended period while staff passed by or entered other rooms, and the resident stated she had placed the call light on to go to the bathroom. The call light was not answered until much later, and the resident was taken to the bathroom after the prolonged wait. Staff interviews indicated the resident typically toileted after breakfast, and another staff member stated the resident was incontinent most of the time. Two other residents also reported long call light waits. One cognitively intact resident reported repeated complaints to administration about waiting 45 to 60 minutes to get out of bed in the morning and said the delays caused morning accidents because she could not hold her urine long enough. Another resident’s wife reported chronic long waits for call light response. Review of grievance records and call light logs showed repeated prolonged response times, including multiple calls lasting from minutes into over an hour, and the administrator confirmed awareness of the long call light grievances and that long call light times remained a problem.
Wheelchair Foot Plate Not Properly Cleaned
Penalty
Summary
The facility failed to ensure proper cleaning of a resident’s wheelchair, specifically the foot plate, for one resident who was cognitively intact, had no behaviors, and used a wheelchair for mobility. The resident required partial to moderate assistance with upper body dressing and substantial to maximal assistance with lower body dressing. During observation and interview, the resident stated the wheelchair foot plate had leftover food on it, that he did not like it, and that he did not know who was supposed to clean it. He also stated he did not remember anyone ever cleaning the foot plate and wished they would. On subsequent observations, crusted food, dried liquid, and dirt remained on the wheelchair foot plate. A nursing assistant stated resident wheelchairs were cleaned on the resident’s designated laundry day, that the cleaning schedule was posted at the nursing station, and that the resident’s wheelchair cleaning day was Thursday. The nursing assistant also stated that if food or beverages were dropped on a foot plate, everyone was responsible for cleaning it immediately, even if it was not the scheduled cleaning day. The nursing assistant and the administrator both stated there was no place to chart that wheelchair cleaning had been completed, and the administrator could not verify when the wheelchair had last been cleaned. A policy for wheelchair cleaning was requested but not received.
Failure to Assess Trauma History and Provide Trauma-Informed Care Planning
Penalty
Summary
The facility failed to appropriately assess a resident with a history of past traumatic experiences and failed to implement person-centered, trauma-informed care plan interventions for one resident with an active diagnosis of PTSD, major depressive disorder, anxiety disorder, bipolar disorder, and mild cognitive impairment. The resident’s quarterly MDS dated 7/8/25 indicated mild cognitive impairment, wheelchair use for mobility, and dependence on staff for hygiene, bathing, dressing, and positioning. The resident’s care plan lacked individualized trauma-informed approaches and did not identify triggers to avoid potential re-traumatization, and the EHR lacked evidence that the facility assessed the resident for trauma. During observations, the resident was repeatedly calling out for staff assistance and asking staff to sit with him; staff sat with him briefly and then left the room. The resident later yelled for help and stated he wanted staff to sit with him again to assist him with eating breakfast, after which he resumed eating without assistance. During interviews, a NA and RN stated they did not know the resident’s trauma history or triggers and confirmed the care plan did not address PTSD. The DON and administrator confirmed the resident had an active PTSD diagnosis, lacked an individualized trauma-informed care plan, and that the trauma assessment was not completed until 12/4/25 and was not followed up. The administrator stated the resident’s PTSD was related to the unexpected suicide death of his brother and that the resident became sad and upset when his family had not visited recently.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to maintain a clean and hygienic environment for a resident who was dependent on staff for mobility in a manual wheelchair. The resident, who was cognitively intact and had conditions such as progressive supranuclear ophthalmoplegia, dysphagia, and anxiety, was observed with a wheelchair that had dried liquids, cereal, and other unidentified dried food items on the seat and cushion. Despite the resident expressing discomfort with the dirty state of the wheelchair, it was not cleaned promptly. Staff interviews revealed that there was a schedule for wheelchair cleaning, but it was the responsibility of all staff to ensure cleanliness. The nursing assistant and registered nurse confirmed that wheelchairs were supposed to be cleaned weekly on the resident's bath day and as needed. However, the resident's wheelchair remained dirty over several days, indicating a failure to adhere to the facility's policy of maintaining wheelchairs in a clean, hygienic condition.
Failure to Maintain Oxygen Therapy for Resident
Penalty
Summary
The facility failed to ensure proper administration and maintenance of oxygen therapy for a resident with respiratory needs. The resident, who had moderately impaired cognition and required assistance with activities of daily living, was diagnosed with respiratory failure, COPD, CHF, dementia, and anxiety. The care plan required the resident to have a full portable oxygen tank before leaving the room and to receive oxygen via nasal cannula as ordered. However, observations revealed that the resident's portable oxygen tank was frequently low or empty, and the oxygen concentrator was not used as intended when the resident was in the room. On multiple occasions, staff failed to check the oxygen levels in the portable tank or ensure the resident was on the concentrator while in the room. The resident was observed with an almost empty portable tank and without the nasal cannula in place, indicating a lack of oxygen flow. Staff, including nursing assistants and a licensed practical nurse, did not verify the oxygen levels or ensure the resident was receiving oxygen as prescribed. The tubing was also found lying on the floor, contrary to facility policy, which posed an infection control risk. Interviews with staff, including a registered nurse and the director of nursing, confirmed that it was the responsibility of the nursing staff to maintain oxygen therapy per provider orders. The facility's policies required regular checks of the oxygen equipment and proper storage of tubing and cannulas. Despite these policies, the staff did not adhere to the procedures, resulting in the resident not receiving the prescribed oxygen therapy consistently.
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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 Cottage Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Therese Of Woodbury Llc | 4.3 mi | ★★★★★ | 10 | 0 |
| Woodbury Health Care Center | 5.3 mi | ★★★★★ | 8 | 1 |
| Woodlyn Heights Healthcare Center | 5.5 mi | ★★★★★ | 17 | 0 |
| Southview Acres Healthcare Center | 6.5 mi | ★★★★★ | 12 | 0 |
| Good Samaritan Society Inver Grove Heights | 6.6 mi | ★★★★★ | 10 | 0 |
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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.