Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Norseland Nursing Home during CMS and state inspections, most recent first.
Surveyors found that food items, including fish fillets, pancakes, bouillon, and onion powder, were not properly dated or discarded according to professional standards. The Dietary Manager confirmed the lack of proper labeling and the presence of expired items, and facility leadership acknowledged that food should be labeled and discarded appropriately.
Several residents reported that their meals were frequently cold and meats were tough to chew, with staff only able to assist with cutting. Surveyors confirmed through test trays that hot foods were served below required temperatures and were not palatable, while cold foods were not properly chilled. The dietary manager acknowledged these issues, which were linked to a recent change in food suppliers and menu adjustments.
A resident with neurological and cognitive impairments experienced significant weight loss due to not consistently receiving required meal-time cueing and supervision as outlined in her care plan. Despite documented difficulties with self-feeding and a recommendation for a nutritional supplement, there was no evidence the supplement was ordered or provided. Staff were not always present to assist during meals, and confusion existed regarding the process for implementing dietary recommendations.
A resident with a history of multiple falls experienced several incidents, including two major injuries, due to the facility's failure to implement and communicate fall prevention interventions. The care plan was not consistently updated or followed, and necessary interventions were not adequately communicated to frontline staff.
The facility failed to maintain an infection prevention and control program, allowing staff to return to work too soon after reporting respiratory and GI symptoms without required testing, as evidenced by multiple instances of non-compliance with facility policies and CDC guidelines.
The facility failed to ensure that residents with limited range of motion received appropriate treatment and services to maintain or improve their mobility. Three residents and one supplemental resident did not receive the prescribed restorative therapy and walking programs. Staff interviews revealed that CNAs were responsible for these tasks, but they were often not completed due to time constraints and staffing issues. The facility's policy on reporting changes in a resident's ability and function was not effectively implemented.
The facility failed to ensure that physician orders were signed and dated in a timely manner for four residents and one supplemental resident. Interviews with nursing staff revealed inconsistencies in the process for managing telephone orders, and the Nursing Home Administrator's expectation for timely signatures was not met, leading to incomplete documentation.
The facility failed to document and maintain advance directives for a resident with severe cognitive impairment, despite the activation of her Power of Attorney as recommended by her physician. The Nursing Home Administrator confirmed the existence of the directives but was initially unable to locate them in the medical record.
A facility failed to develop a baseline care plan within 48 hours for a resident with significant mental health diagnoses, including bipolar depression and PTSD. The care plan did not address the resident's psychosocial needs or prescribed medications, despite facility policy and the resident's intact cognition. Interviews revealed that the care plan lacked necessary interventions due to oversight by the nursing and social services staff.
The facility failed to follow physician's orders for a resident with CHF, including daily weight monitoring and checking oxygen saturation on room air every shift. Staff inconsistencies and policy gaps led to weights being recorded weekly instead of daily and oxygen saturation being checked while the resident was on oxygen.
A resident with dementia and polyosteoarthritis did not receive proper pain management as the facility failed to document pain assessments with scheduled medications. Staff only completed pain assessments for PRN medications, and the resident's care plan lacked a specific pain goal, leading to inadequate pain management.
A facility failed to provide medically related social services for a resident with mental health diagnoses, including bipolar depression, PTSD, and anxiety. The care plan did not address the resident's psychosocial needs or medications, and the social worker missed the physician's recommendation for a social services consult.
The facility failed to ensure that drug regimens were free of unnecessary psychotropic medications and did not include targeted behaviors and side effects in the care plans for two residents. One resident was started on Clonazepam and Citalopram without proper diagnosis and monitoring, while another resident's care plan did not address psychosocial needs or monitor side effects of multiple psychotropic medications.
The facility failed to provide timely Notice of Medicare Non-Coverage to two residents or their responsible parties. One resident's AHCPOA was not given the notice to sign, and another resident did not sign the notice at all, despite the facility's policy requiring these actions.
Failure to Properly Date and Discard Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen tour, food items such as fish fillets and pancakes were found removed from their original packaging and lacked any use by, expiration, or open dates. Additionally, boxes of beef and chicken bouillon in dry storage did not have expiration dates, and an opened container of onion powder was found to be expired. The Dietary Manager confirmed these items were not properly dated and that the expired seasoning should have been discarded. Interviews with the Nursing Home Administrator and the Vice President of Health Services confirmed that their expectation was for all food to be labeled and discarded appropriately. The failure to date and properly manage food items was observed to have the potential to affect all 34 residents in the facility. No specific residents were identified as being directly affected at the time of the survey.
Failure to Provide Palatable and Properly Tempered Food to Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at safe and appetizing temperatures. Multiple residents reported that their meals were often cold, with one resident specifically stating that food was not hot enough when delivered to their room. Another resident indicated that meats, such as ham and beef, were tough to chew, and staff could only assist with cutting, not with the actual chewing. Additional residents voiced concerns about the food being lukewarm and tough, particularly after a recent change in food suppliers. One resident described the food as 'rotten' and stated that the pork chop was 'tough as a brick.' Surveyors conducted test trays in both resident rooms and the main dining room, finding that hot foods were served below the required temperature and were not palatable. For example, a Chicago Beef Sandwich was measured at 113°F and sweet potato fries at 104°F, both below the facility's policy requirement of 135°F for hot foods. Cold items were also not maintained at the correct temperature. The dietary manager acknowledged the issues with food temperature and toughness, noting the recent switch in food companies and ongoing menu adjustments. Facility policy requires hot foods to be held at 135°F or higher and cold foods at 41°F or below, but these standards were not met during the survey period.
Failure to Provide Adequate Nutritional Support and Assistance During Meals
Penalty
Summary
A resident with a history of neurological and cognitive impairments, including corticobasal degeneration and parkinsonism, experienced significant weight loss over a six-month period. The resident's care plan identified her as being at nutritional risk and outlined specific interventions, such as providing cueing and reminders during meals, offering preferred foods, and using adaptive equipment. Despite these documented needs, the resident did not consistently receive the required cueing or supervision during meal times, as observed by the surveyor and confirmed through staff interviews. Meal intake records showed that the resident consumed 50% or less of her meals nearly half the time, and observations revealed frequent difficulties with self-feeding, including dropping food and struggling to use utensils due to physical limitations. The facility's policy required that residents with inadequate oral intake be offered nutritional supplements and that physician orders for nutrition support be communicated to the nutrition services department. Although the registered dietician recommended a nutritional supplement (Ensure) to address the resident's ongoing weight loss, there was no evidence that an order for the supplement was placed or that it was included on the resident's meal card. Staff interviews indicated confusion regarding the process for implementing dietician recommendations and placing supplement orders, with the DON unsure about the current protocol. Further, staff interviews and observations revealed that CNAs were not always present in the dining room at the start of meals to provide necessary assistance, as they were occupied with other duties. Dietary aides were not permitted to assist with feeding or cueing, and CNAs reported that the resident often refused built-up utensils and required increasing assistance with eating. Despite these challenges, there were no documented changes to the resident's nutritional care plan or additional interventions implemented in response to her declining intake and weight loss.
Failure to Implement and Communicate Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for a resident with a history of multiple falls. The resident, who has moderate cognitive impairment and requires assistance with transfers and ambulation, experienced several falls, two of which resulted in major injuries. Despite having a care plan in place, the facility staff did not consistently implement or follow through on fall interventions, such as ensuring the resident used the call light for assistance and performing regular safety checks. Additionally, the care plan was not updated promptly to reflect new interventions after each fall, and the interventions were not adequately communicated to the frontline care staff. The resident's care plan included various fall prevention measures, such as using non-skid footwear, performing hand exercises, and conducting 15-minute safety checks. However, these interventions were not consistently followed. For example, the resident's care plan was not updated to include toileting on the last rounds of the night shift, despite this being identified as a necessary intervention after a fall. Furthermore, the resident's exercise binder, which was supposed to be completed three times a day, showed significant missed opportunities, with exercises only being completed 13 times over a month. The facility also failed to implement other recommended interventions, such as installing non-skid floor strips and ensuring the resident's room had a 'Call Don't Fall' sign. The lack of timely and appropriate interventions, along with poor communication among staff, contributed to the resident experiencing multiple falls, including two that resulted in significant injuries. The facility's failure to create a robust fall care plan and ensure its consistent implementation and communication led to these deficiencies.
Inadequate Infection Prevention and Control Program
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, which has the potential to affect the total census of 42 residents. The facility allowed staff to return to work too soon after reporting respiratory and gastrointestinal (GI) symptoms and did not require staff to be tested for COVID-19 per CDC guidance. This failure was evidenced by multiple instances where staff returned to work without appropriate testing or sufficient symptom-free periods, as outlined in the facility's policies and CDC guidelines. The facility's policy on infection control measures for acute respiratory illness outbreaks and employee illness was not followed. For example, a Certified Nursing Assistant (CNA) returned to work one day after reporting respiratory symptoms without undergoing COVID-19 testing. Similarly, a Registered Nurse (RN) returned to work after experiencing diarrhea without being symptom-free for the required 48 hours. Another CNA returned to work during an influenza outbreak without being tested for influenza or having two negative COVID-19 tests. The Infection Preventionist (IP) acknowledged these discrepancies during an interview, admitting that the documentation and enforcement of the policies were inadequate. The IP confirmed that staff members returned to work too soon and without the necessary testing, which was particularly concerning during an influenza outbreak. The facility's failure to ensure that staff members remained off work for the specified time based on current standards of practice for acute respiratory illnesses and GI symptoms, and the lack of required testing, contributed to the deficiency.
Failure to Provide Prescribed Restorative Therapy and Walking Programs
Penalty
Summary
The facility failed to ensure that residents with limited range of motion received appropriate treatment and services to maintain or improve their mobility. Specifically, three residents and one supplemental resident did not receive the prescribed restorative therapy and walking programs. For instance, one resident had therapy recommendations for using a Med bike four times weekly and passive range of motion exercises daily, but these were not completed. Another resident had orders to participate in a walking program twice a day, but the facility's documentation showed that this was not consistently done. Additionally, two other residents on the restorative walking program did not have documentation to show they were being walked as required. Interviews with staff revealed that the Certified Nursing Assistants (CNAs) were responsible for completing the restorative and walking programs, but these tasks were often not completed due to time constraints and staffing issues. The Director of Nursing (DON) acknowledged that the facility had identified issues with the electronic charting system not triggering staff to chart the restorative program. Despite changes made in January to address this, the restorative therapy exercises and activities were still not consistently completed for each resident. Residents expressed concerns about not receiving their prescribed therapy, which they believed would help improve their mobility and overall condition. Staff interviews indicated that there was a lack of consistent communication and documentation regarding the restorative programs. The facility's policy stated that changes in a resident's ability and function should be reported to the unit nurse for updates and revisions, but this was not effectively implemented. The facility did not ensure that restorative therapy exercises and activities were completed to maintain current abilities, prevent decline, or restore baseline abilities for the affected residents.
Failure to Ensure Timely Physician Signatures on Telephone Orders
Penalty
Summary
The facility did not ensure that physician orders were signed and dated in a timely manner for four residents and one supplemental resident. Specifically, the telephone orders for residents with diagnoses such as Alzheimer's Disease, Type Two Diabetes Mellitus, hyperlipidemia, interstitial pulmonary disease, dementia, and chronic kidney disease were not signed by a physician within the required timeframe. The orders for these residents spanned several months and were not appropriately signed and dated by a physician as required by the facility's policy and federal regulations. Interviews with the facility's nursing staff revealed inconsistencies and confusion regarding the process for obtaining and managing telephone orders. Registered Nurses (RNs) indicated that the orders were entered into the computer system and checked by a second nurse, but the physical copies of the orders were not consistently signed by a physician. The Director of Nursing (DON) and other staff members provided conflicting information about the handling and storage of the carbon copies of the telephone orders, with some indicating that the copies were used for internal communication only and not signed by physicians. The Nursing Home Administrator (NHA) stated that it was her expectation that telephone orders be signed by a physician within ten days. However, the review of the records showed that this expectation was not met, as the orders for the residents in question were not signed within the required timeframe. This deficiency highlights a lack of adherence to the facility's policy and federal regulations regarding physician orders, leading to incomplete documentation and potential risks to resident care.
Failure to Document Advance Directives
Penalty
Summary
The facility failed to ensure that all residents were able to formulate an advance directive, specifically related to code status, for one resident reviewed for advance directives. The facility's policy requires the Social Worker to determine if a resident has any advance directives upon move-in and to assist in creating them if they are not present. Additionally, advance directives should be reviewed at initial and quarterly care conferences, with copies filed in the resident's physical chart. However, the facility did not have the advance directives for a resident with severe cognitive impairment in her medical record, despite the resident's Power of Attorney (POA) being activated as recommended by her physician. The resident in question was admitted with diagnoses including Alzheimer's Disease, Type Two Diabetes Mellitus, and Spinal Stenosis. The resident's medical records indicated severe cognitive impairment and the activation of her POA. During an interview, the Nursing Home Administrator confirmed the existence of the resident's advance directives but was initially unable to locate them in the medical record. The directives were later obtained from the hospital by fax. This deficiency highlights the facility's failure to adhere to its own policy regarding the documentation and maintenance of advance directives in the resident's medical record.
Failure to Develop Baseline Care Plan for Resident's Mental Health Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with significant mental health diagnoses. The resident, admitted from an acute care hospital, had diagnoses including bipolar depression, PTSD, depression, and anxiety. Despite the facility's policy requiring a care plan to be developed within 48 hours, the resident's care plan did not address his psychosocial needs or the medications prescribed for his mental health conditions. The resident's admission MDS indicated intact cognition, and the hospital discharge summary noted word-finding difficulties and slower response times due to a head injury, along with a list of prescribed medications for his mental health conditions. Interviews with the Director of Nursing and the Social Worker revealed that the care plan did not include necessary interventions for the resident's psychosocial needs. The Director of Nursing acknowledged that the care plan should have addressed these needs, while the Social Worker admitted to not including them because they were not listed as problems by the hospital discharging physician. This oversight resulted in the resident's immediate mental health needs not being properly addressed upon admission.
Failure to Follow Physician's Orders for CHF Resident
Penalty
Summary
The facility failed to ensure physician's orders were followed according to professional standards for one resident diagnosed with congestive heart failure (CHF). Specifically, the facility did not adhere to the physician's orders for daily weight monitoring and checking the resident's oxygen saturation on room air every shift. This failure was identified through interviews, record reviews, and facility policy reviews, which revealed that the resident's weights were not consistently recorded daily as ordered, and oxygen saturation was checked while the resident was on oxygen rather than on room air as specified by the physician's orders. The resident, who was admitted with multiple diagnoses including CHF, atrial fibrillation, and type 2 diabetes, had physician's orders for daily weights and oxygen saturation checks on room air every shift. Despite these orders, the facility's electronic medical records showed that weights were often recorded weekly instead of daily, and oxygen saturation was checked while the resident was on oxygen. Interviews with nursing staff and CNAs confirmed that the resident was not consistently weighed daily and that oxygen saturation was not checked on room air as required. The facility's policies on weight monitoring and oxygen use did not specifically address the physician's orders for daily weights for residents with CHF. Staff interviews revealed inconsistencies in understanding and implementing these orders. The Director of Nursing and Nursing Home Administrator acknowledged that the resident's weights should have been recorded daily and that oxygen saturation should have been checked on room air every shift, as per the physician's orders. The failure to follow these orders was a significant deficiency in the care provided to the resident, potentially impacting the management of the resident's CHF and overall health condition.
Inadequate Pain Management Documentation
Penalty
Summary
The facility did not ensure that pain management was provided consistent with standards of practice for a resident who required such services. The resident, who has diagnoses including unspecified dementia, pain in the left knee, and polyosteoarthritis, had orders for scheduled Tylenol and Tramadol pain medication. However, the facility failed to assess the effectiveness of these scheduled pain medications, as evidenced by the lack of pain ratings or assessments documented with the administration of these medications. The resident's care plan indicated a need for pain management, but the facility did not follow through with the necessary evaluations and documentation to ensure the resident's pain was being managed effectively. The facility's policy on Pain Assessment and Monitoring required documentation of pain origin, duration, intensity, and relief measures, as well as notifying the medical doctor of any persistent or uncontrolled pain. Despite this, the resident's medication administration records for February, March, and April showed no pain ratings or assessments with the administration of scheduled pain medications. Additionally, the resident's nurses' progress notes did not mention any non-pharmacologic interventions or pain ratings. Interviews with the facility's staff, including a registered nurse and the director of nursing, revealed that pain assessments were only being completed for PRN (as needed) medications and not for scheduled medications. The director of nursing acknowledged that pain ratings and follow-up assessments were not being completed for scheduled pain medications and should be. Furthermore, the resident's care plan did not include a specific pain goal, making it unclear what the acceptable pain level for the resident was. This lack of documentation and follow-up on the resident's pain management needs led to the deficiency identified by the surveyors.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services for a resident with mental health diagnoses, including bipolar depression, PTSD, and anxiety. Upon admission from an acute care hospital, the resident's discharge summary included a recommendation for a social services consult and a list of prescribed antidepressant medications. However, the resident's care plan did not address his psychosocial needs or the medications administered for his mental health conditions. The social worker admitted to not addressing the resident's psychosocial needs in the care plan, focusing instead on a problem list that did not include mental illness diagnoses. The Director of Nursing confirmed that the care plan should have included interventions from both nursing and social services to address the resident's psychosocial needs. The social worker acknowledged missing the physician's reference for a social services consult in the hospital discharge summary. As a result, the facility did not provide the necessary social service consultation or address the resident's psychosocial needs related to his mental health diagnoses and medication therapy.
Failure to Monitor Psychotropic Medications and Care Plan Targeted Behaviors
Penalty
Summary
The facility did not ensure that drug regimens were free of unnecessary psychotropic medications and failed to include targeted behaviors and side effects in the care plans for two residents. One resident was started on Clonazepam for involuntary body movements and Citalopram for Major Depressive Disorder, despite not having a diagnosis for Major Depressive Disorder. The care plan for this resident did not include mood or behavior monitoring to assess the effectiveness of these medications or any potential side effects. Additionally, the CNA closet card for this resident was blank in the behavior section, and interviews with staff revealed confusion about where to find information on targeted behaviors and potential side effects of medications being taken by residents. The Director of Nursing confirmed that psychotropic medications and targeted behaviors should be included in the care plan but were not in this case. The care plans are reviewed and updated quarterly and as needed, but this was not adequately done for this resident. Another resident was admitted with diagnoses including bipolar depression, PTSD, depression, and anxiousness associated with depression. This resident was administered multiple psychotropic medications, including Lamotrigine, Prazosin, Trazodone, Bupropion, and Escitalopram. However, there were no specific orders for monitoring the side effects or behaviors associated with these medications. The care plan for this resident did not address his psychosocial needs related to his mental illness diagnosis and the antipsychotic medications he was taking. The Medication Administration Record indicated that the medications were administered as ordered but did not include monitoring of side effects or behaviors. The Director of Nursing acknowledged that the care plan did not indicate that nursing or social services had addressed the resident's psychosocial needs or monitored the psychotropic medications for side effects or behaviors. The facility's policy on Psychotropic Medication Review and Gradual Dose Reduction did not include information on care planning targeted behaviors or monitoring for potential side effects of medications being taken. Interviews with staff, including registered nurses and certified nursing assistants, revealed a lack of clarity and consistency in documenting and monitoring targeted behaviors and side effects for residents on psychotropic medications. The Director of Nursing confirmed that these elements should be included in the care plans but were not adequately addressed for the residents in question. This failure resulted in the facility not ensuring that each resident was free of unnecessary psychotropic medications and that comprehensive care plans included targeted behaviors and potential side effects of the medications.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide timely Notice of Medicare Non-Coverage to residents or their responsible parties for two residents. Resident 28, who was receiving Medicare A benefits, had their coverage end on January 30, 2024. Although Resident 28 signed the Notice of Medicare Non-Coverage, the facility did not have the Activated Healthcare Power of Attorney (AHCPOA) sign the form or provide a copy to the AHCPOA, despite the resident not being their own decision maker. This indicates a failure to follow the facility's policy, which requires the notice to be provided to the resident's representative or POA if necessary. Similarly, Resident 33, who was also receiving Medicare A benefits, had their coverage end on January 17, 2024. The resident did not sign the Notice of Medicare Non-Coverage, and the facility did not ensure that the notice was signed or properly documented. The Nursing Home Administrator confirmed that the notice was discussed with the residents but not signed, which is a deviation from the required procedure. This lack of proper documentation and adherence to policy led to the identified deficiency.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 58 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Westby
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vernon Manor | 6.3 mi | ★★★★★ | 11 | 0 |
| Soldiers Grove Health Services | 19.2 mi | ★★★★★ | 0 | 0 |
| Morrow Memorial Home | 19.5 mi | ★★★★★ | 0 | 0 |
| Hillview Health Care Ctr | 19.5 mi | ★★★★★ | 15 | 0 |
| Lakeview Health Center | 19.7 mi | ★★★★★ | 2 | 0 |
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