Inspection Reports for
Norwood Crossing
6016 N Nina Ave, Chicago, IL 60631, IL, 60631
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
194% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 7
Date: Jul 25, 2025
Visit Reason
Routine inspection survey conducted to assess compliance with care standards, medication administration, infection control, accident prevention, and pharmaceutical services at Norwood Crossing nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide timely and adequate care for dependent residents, delayed feeding assistance, malfunctioning pressure ulcer prevention equipment, inadequate supervision of fall-risk residents, unsecured hazardous areas, medication administration delays, improper medication labeling and storage, and lapses in infection control practices.
Deficiencies (7)
F 0677: The facility failed to provide care and assistance for activities of daily living to a dependent resident with bladder and bowel incontinence, resulting in prolonged exposure to wet briefs.
F 0684: The facility failed to provide timely 1:1 feeding assistance to a resident requiring such help, causing the resident to have an uneaten lunch tray for an extended period.
F 0686: The facility failed to ensure a pressure relieving device was functioning properly for a resident at risk for pressure ulcers, as the air mattress pump was initially inoperable.
F 0689: The facility failed to provide adequate supervision for fall-risk residents in the dining room and failed to secure a soiled utility room door containing hazardous materials, posing potential harm to residents.
F 0755: The facility failed to provide medication administration in compliance with professional standards, resulting in five residents receiving scheduled medications late.
F 0761: The facility failed to label medications with opening and expiration dates and failed to discard expired medical supplies, risking improper medication use.
F 0880: The facility failed to implement infection prevention and control protocols, as staff did not wear appropriate personal protective equipment while providing care to a resident on enhanced barrier precautions.
Report Facts
Residents reviewed for ADL care: 24
Residents reviewed for feeding assistance: 24
Residents reviewed for pressure ulcer risk: 7
Residents reviewed for medication administration: 7
Residents affected by medication administration deficiency: 5
Residents affected by infection control deficiency: 1
Residents affected by fall supervision deficiency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 | Director of Nursing | Named in findings related to ADL care, medication administration, infection control, and soiled utility room supervision |
| V5 | Registry Certified Nursing Assistant | Named in ADL care deficiency for resident R56 |
| V6 | Restorative Nurse/Fall Coordinator | Named in pressure ulcer device and fall supervision deficiencies |
| V7 | Registered Nurse | Named in fall supervision deficiency |
| V11 | Assistant Director of Nursing | Named in feeding assistance deficiency |
| V14 | Certified Nursing Assistant | Named in infection control deficiency for failure to wear appropriate PPE |
| V20 | Certified Nursing Assistant | Named in feeding assistance deficiency |
| V21 | Registered Nurse | Named in feeding assistance deficiency |
| V23 | Registered Nurse | Named in feeding assistance deficiency |
| V26 | Registered Nurse | Named in soiled utility room deficiency and medication cart audit |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 22, 2025
Visit Reason
The visit was conducted as a complaint investigation identified as IL192450 to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared House Act.
Complaint Details
Complaint Investigation IL192450; the establishment was found compliant with relevant regulations.
Findings
The establishment was found to be in compliance with the applicable assisted living and shared housing regulations during this complaint investigation.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: Feb 26, 2025
Visit Reason
The inspection was conducted due to a complaint or allegation regarding medication storage and treatment cart security practices at the facility.
Complaint Details
The investigation was complaint-related, focusing on medication storage and treatment cart security. The findings were substantiated with observations and interviews confirming policy violations.
Findings
The facility failed to ensure medications were not left at the bedside without physician orders and failed to keep treatment carts locked when unattended. These issues potentially affected all 36 residents on the 4th floor.
Deficiencies (2)
F 0761: The facility failed to ensure medications were not left at the bedside for one resident without a physician order. Medications were found unsecured on the bedside cabinet.
F 0761: The facility failed to ensure treatment carts were locked when not in use or not in visual proximity of nursing staff. Unlocked carts were observed on multiple floors.
Report Facts
Residents affected: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 ADON | Assistant Director of Nurses | Interviewed regarding medication storage policy and treatment cart security |
| V5 RN | Registered Nurse | Interviewed about medication storage and treatment cart policy; assigned nurse for resident R2 |
| V2 DON | Director of Nurses | Provided statements on medication and treatment cart locking policies |
| V6 RN | Registered Nurse | Interviewed about treatment cart left unlocked |
| V11 RN | Registered Nurse | Interviewed about treatment cart locking policy after observation of unlocked cart |
| V12 RN | Registered Nurse / Infection Preventionist | Provided statements on medication storage and cart locking policies |
| V16 CNA | Certified Nurse Assistant | Provided information about nurse break and treatment cart status |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Feb 20, 2025
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory standards related to resident dignity, wound care treatment, and food safety in the facility.
Findings
The facility failed to ensure one resident was treated with dignity due to posting wound care instructions on the resident's walls. The facility also failed to provide appropriate wound care treatment for one resident, with missing documentation for wound dressing changes. Additionally, the facility failed to properly log refrigerator and freezer temperatures and the checking of food item dating and labeling, potentially affecting all residents.
Deficiencies (3)
F 0550: The facility failed to honor the resident's right to dignity by posting wound care instructions on the resident's walls, violating privacy and confidentiality policies.
F 0684: The facility failed to provide appropriate wound care treatment and services as ordered for one resident, with missing documentation for wound dressing changes on multiple dates.
F 0812: The facility failed to properly log refrigerator and freezer temperatures and the checking of food item dating and labeling, documenting future dates instead of actual dates, risking food safety for all residents.
Report Facts
Residents affected: 1
Residents affected: 104
Wound measurement: 2.8
Wound measurement: 1
Wound measurement: 0.1
Wound measurement: 5
Wound measurement: 2
Wound measurement: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (V6) | Stated placing signs on resident's wall and discussed wound care issues | |
| Director of Nursing (V3) | Commented on posting instructions on walls and wound care documentation | |
| Director of Dietary Services (V4) | Discussed kitchen temperature logging and food safety documentation errors |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 26, 2025
Visit Reason
The investigation was conducted due to a complaint regarding inadequate supervision of a high fall risk resident (R5) which resulted in an unwitnessed fall and injury.
Complaint Details
The complaint investigation substantiated that the facility did not provide adequate supervision to resident R5, a high fall risk resident with lung and brain cancer, leading to an unwitnessed fall and fracture. Staff interviews revealed lapses in monitoring during a lunch break and failure to notify the director of nursing for assistance.
Findings
The facility failed to provide adequate supervision for resident R5, a high fall risk individual, resulting in an unwitnessed fall and an acute nondisplaced fracture of the L5 vertebra. Multiple staff statements and clinical records confirmed insufficient monitoring, especially during a lunch break, contributing to the fall.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in a resident's fall and injury.
Report Facts
Residents affected: 3
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V7 | Registered Nurse | Named in supervision failure and fall incident notes |
| V11 | Certified Nurse Assistant | Named in supervision failure and fall incident notes |
| V12 | Nurse Practitioner | Provided clinical assessment and testimony regarding resident R5 |
| V3 | Director of Nursing/Fall Coordinator | Provided investigation statement on supervision failure |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 8, 2025
Visit Reason
The visit was conducted as an annual licensure inspection to determine compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living and shared housing regulations during this annual licensure survey.
Inspection Report
Routine
Deficiencies: 10
Date: Jun 14, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with healthcare regulations and standards at Norwood Crossing nursing home.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, care plan updates, pressure ulcer prevention, restorative care, nutritional monitoring, respiratory care, medication labeling and storage, food safety, and infection prevention and control practices.
Deficiencies (10)
F 0554: The facility failed to ensure a resident self-administering medications had a self-administration assessment, physician's order, and care plan completed.
F 0578: The facility failed to ensure provider orders and care plans reflected residents' wishes on Provider Order for Life-Sustaining Treatment (POLST) forms for one resident.
F 0657: The facility failed to follow physician orders and update a resident's care plan for one resident requiring one-to-one feeding assistance.
F 0686: The facility failed to ensure proper linens and functioning low air loss mattresses were used for residents at risk for pressure ulcers.
F 0688: The facility failed to apply splints and complete quarterly restorative assessments for one resident with limited range of motion.
F 0692: The facility failed to obtain monthly weights and address significant weight loss for three residents, resulting in actual harm.
F 0695: The facility failed to ensure residents' oxygen was on correct settings, oxygen tubing was connected and labeled, and respiratory supplies were stored properly for multiple residents.
F 0761: The facility failed to label a personal use medication, discard expired medications, discard open medications not in original packaging, and return discontinued medications.
F 0812: The facility failed to label, date stored food, discard expired food, and store food separately from cleaning products, risking foodborne illness.
F 0880: The facility failed to maintain enhanced barrier precautions for residents, failed to educate visitors on isolation precautions, failed to maintain suction equipment properly, and failed to update infection control policies annually.
Report Facts
Residents in sample: 22
Facility census: 109
Weight loss percentage: 15.7
Weight loss percentage: 6.28
Weight loss in pounds: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided statements on oxygen therapy, weight monitoring, medication cart responsibilities, and infection control |
| V7 | Agency Registered Nurse | Observed and commented on oxygen tubing and medication self-administration |
| V10 | Nurse | Observed medication cart, administered medications, and handled suction equipment |
| V19 | Infection Prevention Nurse | Provided infection control education and policy information |
| V12 | Registered Dietitian | Discussed weight monitoring and nutritional assessments |
| V13 | Regional Nutrition Director | Discussed weight monitoring and nutritional assessments |
| V22 | Wound Care Nurse/Restorative Nurse Supervisor | Discussed pressure ulcer prevention and restorative care |
| V9 | Nurse | Observed medication cart and medication storage issues |
| V6 | Registered Nurse | Observed oxygen and suction equipment storage |
| V8 | Food Service Director | Observed food storage and safety issues |
Inspection Report
Routine
Deficiencies: 6
Date: Aug 8, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, infection control, food service, and equipment use at Norwood Crossing nursing home.
Findings
The facility was found deficient in multiple areas including delayed feeding of dependent residents requiring 1:1 assistance, call light accessibility, pressure ulcer prevention, respiratory care, food labeling and storage, and infection control practices related to cleaning shared equipment. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (6)
F 0550: The facility failed to ensure dependent residents requiring 1:1 feeding assistance were fed timely and with dignity, resulting in delays up to 1 hour and 34 minutes for feeding four residents.
F 0558: The facility failed to ensure the call light was within reach for one resident, compromising their ability to summon assistance.
F 0686: The facility failed to ensure a low air loss mattress was turned on and operating for pressure ulcer prevention for one resident at risk.
F 0695: The facility failed to administer oxygen per physician orders and failed to store oxygen tubing in protective plastic bags for two residents.
F 0812: The facility failed to properly label, date, and store food items and failed to store equipment separately from bulk food bins, risking cross contamination affecting all residents.
F 0880: The facility failed to clean and disinfect shared blood pressure machines and pulse oximeters between resident uses, risking infection spread for four residents.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 112
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 | Director of Nursing | Provided statements on feeding assistance expectations, call light policy, oxygen tubing storage, and infection control practices |
| V9 | Registered Nurse | Observed failing to clean blood pressure machine and pulse oximeter between resident uses |
| V8 | Certified Nurse Assistant | Admitted responsibility for call light being out of reach |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 2, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision and individualized fall prevention interventions for a resident (R1) who sustained a serious fall injury.
Complaint Details
The investigation was triggered by complaints about inadequate supervision and fall prevention for resident R1. The complaint was substantiated as the resident sustained multiple falls, including one causing a serious fracture. Staff interviews and record reviews confirmed insufficient fall interventions and supervision.
Findings
The facility failed to implement adequate fall prevention measures for resident R1, resulting in multiple falls including a serious fall causing a displaced fracture requiring surgery. Staff reported challenges in monitoring R1 due to her wandering behavior and cognitive impairment. The facility's fall interventions were limited and not fully accepted by the resident's family.
Deficiencies (1)
F 0689: The facility failed to provide adequate supervision and individualized fall prevention interventions for resident R1, resulting in multiple falls including a displaced femoral neck fracture requiring surgical repair.
Report Facts
Fall incidents: 4
Date of survey completion: Aug 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V11 | Registered Nurse | Reported on 7/11/23 fall incident involving resident R1. |
| V12 | Licensed Practical Nurse | Assisted during 5/8/23 fall incident involving resident R1. |
| V13 | Agency Registered Nurse | Documented progress notes on 4/29/23 fall incident involving resident R1. |
| V2 | Director of Nursing/Fall Coordinator | Oversaw fall incidents and interventions for resident R1. |
| V9 | Medical Director | Provided medical oversight and orders following resident R1's fall on 5/8/23. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 16, 2023
Visit Reason
The inspection was conducted following a complaint regarding inadequate supervision and improper transfer practices that resulted in a resident sustaining a skin tear injury.
Complaint Details
The complaint investigation found that the resident (R2) sustained a skin tear during transfer from wheelchair to bed on 3/2/23. The injury required hospital evaluation and sutures. The CNA transferring the resident did not use a gait belt as required by facility policy. The resident was a one-person transfer but was changed to a two-person transfer after the incident. The incident was substantiated.
Findings
The facility failed to ensure adequate supervision and proper use of assistive devices during resident transfers, resulting in a resident sustaining a skin tear requiring sutures. Staff failed to use a gait belt during transfer, contrary to facility policy.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents. A resident sustained a skin tear during transfer due to improper transfer technique and lack of gait belt use.
Report Facts
Length of skin tear: 9
Skin tear size: 7
Number of sutures: 8
Date of incident: Mar 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V13 | Certified Nursing Assistant (CNA) | Named in transfer incident causing resident injury |
| V2 | Director of Nursing (DON) | Present during interviews and stated facility policy on gait belt use |
| V16 | Assistant Director of Nursing (ADON) | Present during incident review and stated CNA should have used gait belt |
| V11 | Registered Nurse (RN) | Provided care to resident after injury and confirmed gait belt policy |
| V12 | Registered Nurse (RN) | Confirmed injury and gait belt policy |
| V7 | Medical Director | Commented on injury and possible prevention with gait belt use |
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