Norris Square

In the surveyor’s words

From the most serious findings on record at Norris Square, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 3, 2023

  Based on observation, interview, and document review, the facility failed to perform timely comprehensive skin assessments, and implement interventions to promote healing and reduce the risk for further pressure ulcer development for 1 of 2 resident (R22) who was admitted to the facility without pressure ulcers. This resulted in harm for R22 when the facility failed to develop interventions to promote healing and prevention resulting in R22 developing three pressure ulcers. Findings include: A stage one pressure injury is intact skin with a localized area of redness that is non-blanchable (does not turn white when pressed). A stage two pressure ulcer is partial thickness loss of the skin with exposed dermis, presenting as a shallow open ulcer. […]

• No harm, potential for more than minimal, patternF550Sep 23, 2021

  Based on observation, interview and document review the facility failed to ensure a dignified dining experience for residents during meals in the dining room for 4 of 4 residents (R7, R12, R38, R41) reviewed for assistance meals. Findings include: R7's admission Minimum Data Set (MDS) dated [DATE], indicated R7 was cognitively intact, required supervision for eating . R7's care plan dated 9/7/21, nutritional problem related [CONDITION(S)] and dementia. Interventions included provide, serve diet as ordered. Monitor intake per facility policy. Staff were to offer additional fluids as ordered and assist with all feeding needs. […]

• No harm, potential for more than minimal, patternF761Sep 23, 2021

  Based on observation, interview, and document review, the facility failed to ensure stock medication were discarded after expiration on 1 of 3 medication carts, potentially affecting 13 of 13 residents on that unit. In addition, the facility failed to ensure resident's personal medication was discarded after expiration for 1 of 13 residents (R28). Findings include: During the medication tour of the 2-south unit on 9/22/21, at 1:41 p.m. with registered nurse (RN)-A multiple expired medications were observed in the medication cart. The following concerns were identified: R28's acetaminophen suppositories 650 milligram (mg) with expiration date of 5/4/21. R28's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF565Dec 10, 2025

  Based on observation, interview, and document review, the facility failed to develop interventions to ensure residents call lights were answered in a timely manner for 3 of 3 residents (R5, R21, R37) who filed grievances related to long call light times.Finding include: R5 R5's quarterly Minimum Data Set (MDS) assessment, dated 11/21/25 indicated R5 was cognitively intact with no behaviors. R5 had no upper or lower body range of motion impairment and requires substantial assist for toileting hygiene and transfers. R5's diagnoses list included generalized muscle weakness and abnormal gait/mobility. R5's care plan included 1 assist for activities of daily living, bed mobility, and 1 assist with stand (mechanical) lift for transferring. […]

• No harm, potential for more than minimal, isolatedF584Dec 10, 2025

  Based on observation and interview, the facility failed to ensure proper cleaning of wheelchairs for 1 of 1 resident (R38) reviewed for safe, clean, and homelike environment.Findings include:R38's quarterly Minimum Data Set (MDS) assessment, dated 11/21/25, included R38 was cognitively intact with no behaviors. R38 used a wheelchair for mobility, required partial to moderate assistance with upper body dressing, required substantial to maximal assistance for lower body dressing.During observation and interview on 12/8/25at 2:57 p.m., R38 stated his wheelchair foot plate has left over food on it; he doesn't like it but doesn't know who is supposed to clean it. […]