Inspection Reports for
Norwood Crossing

F0677 - The facility failed to ensure ADL care was provided for dependent residents requiring assistance with bladder and bowel incontinence for one resident (R56).

F0684 - The facility failed to provide 1:1 feeding assistance in a timely manner for one resident (R2).

F0686 - The facility failed to ensure a pressure relieving device was functioning properly for one resident (R20) at risk for pressure ulcers.

F0689 - The facility failed to provide adequate supervision and monitoring for fall risk residents and failed to ensure a dependable locking mechanism on a soiled utility room door, affecting multiple residents (R22, R34, R55, R60, R63, R67) and all residents on the second floor.

F0755 - The facility failed to provide medication in compliance with standards of professional practice for five residents (R19, R32, R39, R58, R77) by administering scheduled medications late.

F0761 - The facility failed to label medications when opened, failed to label medications with expiration dates, and failed to dispose of expired medical supplies, affecting residents receiving medications from the second and third floor medication carts.

F0880 - The facility failed to practice infection control and prevention by not ensuring appropriate personal protective equipment (PPE) was worn by staff caring for a resident (R6) on enhanced barrier precautions.

F0761 (Medication Storage) - The facility failed to ensure medications were not left at bedside for one resident and failed to ensure treatment carts were locked when unattended on multiple occasions.

F0550 (Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights) - The facility failed to ensure that one resident was treated in a dignified manner by posting signs on the resident's walls that compromised confidentiality and dignity.

F0684 (Provide appropriate treatment and care according to orders, resident’s preferences and goals) - The facility failed to ensure that one resident with a venous stasis ulcer received necessary wound care treatments as ordered, with multiple missed dressing changes documented.

F0812 (Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards) - The facility failed to properly log refrigerator and freezer temperatures and the checking of dating and labeling of food items, documenting future dates instead of actual dates, potentially affecting all residents receiving an oral diet.

F0689 - The facility failed to provide adequate supervision for one resident who is a high fall risk, resulting in an unwitnessed fall and an acute nondisplaced fracture of the L5 vertebra.

F0554 (Allow residents to self-administer drugs if determined clinically appropriate) - The facility failed to ensure a resident self-administering medications had a self-administration assessment, physician's order, and care plan completed.

F0578 (Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive) - The facility failed to ensure the provider order and care plan reflected a resident's wishes on the POLST form.

F0657 (Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals) - The facility failed to update a resident's care plan to reflect physician orders for one-to-one feeding assistance.

F0686 (Provide appropriate pressure ulcer care and prevent new ulcers from developing) - The facility failed to ensure proper linens and correct settings on low air loss mattresses for residents at risk of pressure ulcers.

F0688 (Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason) - The facility failed to apply splints and complete quarterly restorative assessments for a resident with limited range of motion.

F0692 (Provide enough food/fluids to maintain a resident's health) - The facility failed to obtain monthly weights and recognize, evaluate, and address significant weight loss for multiple residents.

F0695 (Provide safe and appropriate respiratory care for a resident when needed) - The facility failed to ensure oxygen was on correct settings, tubing was connected and functioning, supplies were labeled and dated, and respiratory supplies were stored to prevent contamination.

F0761 (Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs) - The facility failed to label personal use medication, discard medications past the 'Best By' date, discard open medications not in original packaging, and return discontinued medications.

F0812 (Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards) - The facility failed to label and date stored food, discard expired food, and store food items separate from cleaning products.

F0880 (Provide and implement an infection prevention and control program) - The facility failed to maintain enhanced barrier precautions for residents, failed to educate visitors on contact isolation precautions, failed to maintain suction equipment properly, and failed to annually update infection prevention policies.

F0550 (295.5500 Resident Rights) - The facility failed to ensure dependent residents requiring 1:1 feeding were treated with respect and dignity by not being fed simultaneously with other residents, affecting 4 residents during dining observations.

F0558 (295.5580 Resident Rights) - The facility failed to ensure the call light was within reach for one resident reviewed for call lights.

F0686 (295.6860 Resident Care) - The facility failed to ensure an air mattress used for pressure reduction was on and operating while the resident was in bed for one resident reviewed for wound prevention.

F0695 (295.6950 Respiratory Care) - The facility failed to follow policy by not administering oxygen per physician's orders and not storing oxygen tubing in a protective plastic bag when not in use for two residents reviewed for respiratory care.

F0812 (295.8120 Food Service) - The facility failed to ensure food items were properly labeled, dated, and stored and failed to store equipment separately from bulk food bins, potentially affecting all 112 residents receiving food prepared in the kitchen.

F0880 (295.8800 Infection Control) - The facility failed to ensure shared equipment was cleaned and decontaminated between each use for four residents reviewed for medication administration observation.

F0689 - The facility failed to provide adequate supervision and follow its fall policy by not implementing individualized fall prevention interventions for one of three residents reviewed, resulting in a fracture requiring surgical repair.

F0689 (Nursing Home Safety) - The facility failed to ensure adequate supervision and use of assistive devices during transfer, resulting in a skin tear injury to one resident.