Norwood Crossing

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 2, 2026

  Based on interview and record review, the facility failed to supervise one resident (R1) who was a high risk for falls. This failure resulted in R1 falling to the floor and sustaining a broken clavicle. This failure affected one of three residents reviewed for falls.Findings include:R1's diagnoses include but are not limited to epilepsy, muscle weakness, difficulty walking, lack of coordination, muscle wasting and atrophy, dementia.R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 11, indicating R1's cognition is moderately impaired. […]

• Actual harm, isolatedF689Jan 26, 2025

  Based on interviews and record reviews, the facility failed to provide adequate supervision for one resident [R5] who is a high fall risk out of three residents reviewed for falls. This failure resulted in R5 experiencing an unwitnessed fall and sustaining an acute nondisplaced fracture of the L5 superior endplate with extension to the left L5 transverse process (Lumbar Fracture). Findings Include, R5 clinical record indicate in part; R5 is a sixty-nine year old with the Medical diagnosis includes but not limited to malignant neoplasm of right main bronchus, secondary malignant neoplasm of brain, severe protein calorie malnutrition, atrial fibrillation, osseous and subluxation, major depressive disorder, wedge compression fracture of fifth lumbar vertebra, subsequent encounter for fracture… […]

• Actual harm, isolatedF692Jun 14, 2024

  Based on interviews and record reviews, the facility failed to obtain monthly weights and recognize, evaluate, and address weight loss for three (R17, R66, and R61) residents out of a total sample of 22 residents. This failure resulted in R17 having a 15.7 percent decrease in weight in six months between 12/4/2023 (121 pounds) and 6/4/2024 (102 pounds). Findings include: 1. On 6/11/2024 at 10:48 AM and at 1:26 PM, R17 was observed sleeping in bed with an intravenous (IV) in the left hand and 0.9 percent Dextrose with Sodium Chloride running at a rate of eighty milliliters per hour. On 06/11/24 at 2:47 PM V9 (Registered Nurse) stated that R17 felt weak, threw up and had diarrhea the morning of 6/11/2024. R17's blood pressure was also low. […]

• Actual harm, isolatedF689Aug 2, 2023

  Based on interviews and record reviews the facility failed to provide adequate supervision and failed to follow their fall policy by failing to develop and implement indivualized fall prevention interventions for one of three residents (R1) reviewed for falls on the sample list of three. This failure resulted in R1 sustaining a closed displaced fracture of the left femoral neck requiring surgical intervention. Findings Include: R1's clinical record documents: R1's medical diagnosis of displaced intertrochanteric fracture of left femur, Alzheimer's disease, dementia with behavior disturbances, anxiety, essential hypertension, unsteadiness on feet, reduced mobility, need for assistance with personal care, and history of falling. […]

• Actual harm, isolatedF689Mar 16, 2023

  Based on observation, interview and record review the facility failed to ensure the resident received adequate supervision and assistive devices to prevent serious injury to the resident. This failure affected one (R2) of three residents (R1, R2 and R8) reviewed for accident prevention by not using proper transfer practices. This failure resulted in R2 sustaining a skin tear during transfer, which required sutures at the local hospital. Findings include: R2 is a [AGE] year-old female resident with diagnoses including Heart Failure, Dementia with Psychotic Disturbance and History of Falls. R2's BIMS (Brief Interview for Mental Status) score indicated R2 is not able to be interviewed. Minimum Data Set scores R2 at 3 (Extensive Assistance) with 2 (One-person physical assist) for transfer. […]