Norwood Healthcare

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Feb 9, 2026

  Based on record review and interviews, the facility failed to develop, maintain, and implement an active, interdisciplinary, person centered care plan to address a known elopement risk for one Resident (#83), in a sample of 25, despite documented severe cognitive impairment (BIMS=3 on 11/24/25), exit seeking behavior, and a high risk elopement score of 14 (11/18/25). The facility resolved the elopement/wandering care plan on 11/28/25 without IDT review or subsequent risk reassessment, and did not implement effective interventions (e.g., wander alert specifications, door/elevator supervision) consistent with assessed needs. […]

• Immediate jeopardy, isolatedF689Feb 9, 2026

  Based on observation, record review, and interview, the facility failed to ensure adequate supervision and interventions were implemented to prevent accidents for one Resident (#83), out of a total sample of 25 residents. Specifically, the facility failed to ensure an elopement/wandering care plan and interventions for a resident assessed at high risk for elopement (score 14, 11/18/25) was maintained and implemented, failed to include the Resident in the elopement photo/binder alert system, and failed to prevent unsupervised exit through the main door, resulting in an elopement on 1/17/26. Resident #83 was not discovered missing from the facility until 5:00 P.M. […]

• Immediate jeopardy, isolatedF689May 9, 2024

  Based on observations, interviews and records reviewed, for one of three sampled Residents (Resident #1), whose history included a traumatic subarachnoid hemorrhage without loss of consciousness and unspecified intracranial injury without loss of consciousness (traumatic brain injury/TBI), after being hit by a car as a pedestrian, who had limited attention/concentration and impaired judgement/insight, had a court appointed legal guardian, resided on a secured unit, and who was assessed and care planned for the need for staff supervision while smoking and using smoking materials, the Facility failed to ensure they provided an adequate level of staff to supervise the outside smoking area, as well as monitor and supervise the facility lobby during smoking break times to prevent an… […]

• Immediate jeopardy, isolatedF656Oct 11, 2023

  Based on observation, interviews and records reviewed, for one of three sampled Residents (Resident #1), who had a history of being homeless, with alcohol and substance abuse disorders, was assessed to be at risk for elopement and his/her care plan indicated he/she was to remain in the Facility unless supervised due to a history of elopement, the Facility failed to ensure staff consistently implemented and followed interventions from his/her Plans of Care related to Elopement and Smoking, for safety. On 10/01/23, Resident #1 left his/her secure second-floor unit (North 2), unsupervised and unbeknownst to staff, took the elevator down to the first floor lobby and exited the Facility through a locked front door. […]

• Immediate jeopardy, isolatedF689Oct 11, 2023

  Based on observation, interview and records reviewed, for one of three sampled Residents (Resident #1), who had a history of being homeless, with alcohol and substance abuse disorders, resided on a secured unit in the facility, who was to remain in the Facility unless supervised due to a history of elopement and had an activated Health Care Proxy, the Facility failed to ensure he/she was provided with an adequate level of staff supervision to maintain his/her safety in an effort to prevent an elopement. On 10/01/23, Resident #1 left his/her secure second-floor unit (North 2), unsupervised and unbeknownst to staff, took the elevator down to the first floor lobby and exited the Facility through a locked front door. […]