Norwood Healthcare

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who in the morning on 3/31/26 exhibited signs of acute pain in his/her right shoulder and arm, and had a new Physician's order for a STAT (without delay, immediately) x-ray, the Facility failed to ensure that he/she was provided with radiology services consistent with his/her Physician's Orders, when nursing did not follow up on the order and a STAT x-ray was not obtained, as a result he/she had to be transferred to the Hospital Emergency Department the following day to obtain an x-ray. Findings Include:Resident #1 was admitted to the Facility in March 2025, diagnoses included Alzheimer's, dementia, lack of coordination, difficulty walking, and history of falling. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. and was located by the police at a South Boston train station, approximately 21 miles away, and hospitalized , placing the Resident at immediate risk of serious harm and death.

Inspectors wroteBased on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities and failed to maintain a QAPI program which addressed the full range of care and services including clinical care.

Inspectors wroteBased on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities.

Inspectors wroteBased on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility's Director of Nurses (DON) and Infection Preventionist (IP) failed to attend and participate in three of the last three quarterly QAPI meetings.

Inspectors wroteBased on document review and interview, the facility failed to provide training and education to all their staff to outline current elements, projects, goals, and revisions of the facility's Quality Assurance Performance Improvement (QAPI) program.

Inspectors wroteBased on review of Resident Council Minutes, interviews, and record reviews, the facility failed to ensure concerns brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents had the right to voice and formulate grievances, have those grievances responded to promptly, and be provided a resolution to their grievance. Specifically, the facility failed to:1. Ensure residents had access to grievance forms and were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s); and2. Maintain evidence demonstrating the results of all grievances for a period of no less than three years from the issuance of the grievance decision.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one Resident (#8), out of a total sample of 23 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed to ensure a physician's order to increase Trazodone (antidepressant/used for behavior management) was transcribed into the electronic medical record and implemented.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the necessary vision services were provided for one Resident (#1), out of a total sample of 23 residents.

Inspectors wroteBased on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident (#24), out of a total sample of 23 residents, was invited to his/her care planning meetings to participate in their plan of care.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure one Resident (#8), out of a total sample of 23 residents, was free from unnecessary psychotropic medications by ensuring an as needed (PRN) dose of Zyprexa (antipsychotic) was limited to 14 days.

Inspectors wroteBased on document review and interview, the facility failed to ensure that monthly Medication Regimen Reviews (MRR) were addressed and implemented in a timely manner for one Resident (#6), out of a total sample of 23 residents. Specifically, the facility failed to ensure a recommendation by the pharmacy consultant to obtain a Vitamin D level to consider tapering down the Vitamin D dose and signed by the physician was reviewed by nursing, transcribed, and implemented per the provider's order.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure four of four kitchenettes were maintained in a clean, sanitary condition.

Inspectors wroteBased on record review and interview, the facility failed to provide written documentation related to transfer discharge notices and bed hold policy to the responsible person/invoked Health Care Proxy (HCP) upon five hospitalizations for one Resident (#8), out of a total of 23 sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility document review, the facility failed to ensure one Resident (#82), out of a total sample of 23 residents received food prepared in a form to meet the resident's individual dietary needs. Specifically, the facility failed to upgrade his/her diet per the Speech Language Pathologist (SLP) order for 14 days.

Inspectors wroteBased on record reviews and interviews for one of three sampled residents (Resident #1), who had a Physician's Order for weekly weights times four (4) weeks, the Facility failed to ensure nursing provided care and services that met professional standards of quality, when his/her weights were not obtained per his/her Physician Order.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had an activated Health Care Agent (HCA), the Facility failed to ensure that his/her HCA received written notice, including the reason for the change, when on 12/13/24 Resident #1's was moved to a new room without obtaining consent from and notifying his/her HCA of the room change.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to report ensure they reported an allegation of abuse to the Department of Public Health (DPH) within two hours, as required. On 01/02/25, Resident #1 was observed with an injury of unknown origin and the Facility did not report the incident to DPH, until 02/02/25, a month after the injury had been identified.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure a thorough investigation was conducted related to an injury of unknown origin, when on 01/02/25 after staff found a bump on Resident #1's left forehead, the Facility was unable to provide documentation to support they conducted an investigation, into the injury.

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #1 and #2), who upon admission were each identified as at risk for falls, the Facility failed to ensure after they experienced a witnessed and/or unwitnessed fall, that their plans of care were reviewed and revised for new interventions goals, and outcomes, as needed.

Inspectors wroteBased on interview and record review, the facility failed to employ a full time Social Worker as required for any facility with more than 120 beds.

Inspectors wroteBased on record review and interview, the facility failed to ensure a [NAME] treatment plan (court approved treatment plan for the administration of antipsychotic medications) was active and current for administration of an antipsychotic medication for two Residents (#16 and #25), out of 39 sampled residents with legal guardians (a person who has been appointed by a court or otherwise has the legal authority to care for the personal and property interests of another person who is deemed incapacitated). The facility identified an additional 21 residents with legal guardians that are being administered antipsychotic medication and require a [NAME] Treatment plan. Of these 21 residents, the facility failed to ensure 19 residents had valid, court approved [NAME] treatment plans in place for the administration of antipsychotic medication.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment on one unit out of a total of four units. Specifically, the facility failed to ensure the North Two unit temperature was maintained between 71-81 degrees Fahrenheit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services to three Residents (#51, #31, #17), out of a total sample of 39 residents. Specifically, the facility failed to maintain sanitary conditions of respiratory equipment, including nasal cannula tubing, nebulizer mask/tubing, bilevel positive airway pressure (BiPAP) mask/tubing, and/or continuous positive airway pressure (CPAP) mask/tubing to decrease the risk of potential contamination of germs and/or exposure to infection.

Inspectors wroteBased on record review and interview, the facility failed to address a history of trauma (results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being) identified on trauma assessments and failed to thoroughly assess and to develop a plan of care accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for one Resident (#8), with a self-reported history of trauma, out of a total sample of 39 residents.

Inspectors wroteBased on observations and interview, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to ensure the treatment carts were locked when not in direct supervision of the licensed nurse on three of three units.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date food products in the main kitchen.

Inspectors wroteBased on record review and interview, the facility failed to maintain medical records that were complete and accurate within accepted professional standards of practice for six Residents (#86, #96, #24, #12, #45 and #54), out of a total sample of 39 residents. Specifically, the facility failed to: 1. Ensure physician visits were available in the medical record within a timely manner for Residents #86 and #96; 2. Ensure the medical record contained accurate information regarding Residents #24 and #12's suprapubic tube (a tube surgically placed to empty the bladder of urine); and 3. Ensure clinical Substance Abuse assessments and notes were readily accessible and part of the medical record for Residents #45 and #54. The facility identified an additional 32 residents diagnosed with alcohol abuse and/or substance abuse. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Maintain a complete and accurate system of surveillance and analyze their collected surveillance data to identify any trends of actual or potential infections within the facility to validate the effectiveness of their program; 2A. For Resident #86, who has a gastrostomy tube (feeding tube), ensure staff use appropriate personal protective equipment (PPE) for enhanced barrier precautions (EBP) when providing care; B. For Resident #3, ensure staff use the appropriate PPE for EBP when providing catheter care; and C. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the Physician and/or responsible party of recommendations or changes in condition for two Residents (#86 and #8), out of a total sample of 39 residents. Specifically, the facility failed: 1. For Resident #86, to notify the Physician of recommendations from the Dietitian for a change in nutritional formula to enhance the caloric intake of the malnourished Resident; and 2. For Resident #8, to notify the Health Care Proxy (HCP- health care agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions) when the Resident developed a deep tissue injury to the left heel and a stage 3 pressure wound (full thickness tissue loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for two Residents (#109, #58), out of a total sample of 39 residents. Specifically, the facility failed: 1. For Resident #109, to develop and implement a care plan to address the Resident's chronic pain and pain management; and 2. For Resident #58, to develop and implement a care plan to address the care and management of the Resident's left hand and elbow contracture.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure professional standards of care were met for one Resident (#107), out of a total sample of 39 residents. Specifically, the facility failed to ensure staff provided care and maintained the central venous catheter (CVC) tunneled into the right jugular (vein in the neck) of Resident #107 for medication infusions in accordance with current standards.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to monitor and document the range of motion (ROM) for a resident admitted with left arm contractures, failed to implement recommendations from the Occupational therapy assessments for contracture management, and failed to educate the staff on proper application of the position devices currently in use for one Resident (#58), out of a total sample of 38 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff provided residents with an environment free from accident hazards. Specifically, the facility failed to ensure: 1. On one unit of three units, hazardous items were stored in a secure location and were not easily accessible to residents on the South 2 Unit; and 2. For Resident (#54) and one unit (Unit 2) of three units in the facility, nail clippers, diabetic testing supplies and medications (not prescribed by the Resident's physician) were not stored in the Resident's bureau and were not easily accessible to the Resident and wandering residents on the unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services for the care of an indwelling suprapubic catheter (tube that drains urine from the bladder through a small incision in the lower abdomen and into a collection bag outside the body) for one Resident (#12), out of total sample of 29 residents. Specifically, the facility failed to ensure the Resident's suprapubic catheter device was maintained in a sanitary way.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Notice of Transfer/Discharge was issued to two Residents (#16 and #25), out of a sample of 39 residents. Specifically, the facility failed to notify the Resident/Resident Representative in writing for the reason of transfer and send a copy of the notice to the ombudsman when emergently transferred to the hospital.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Bed Hold Policy Notice was issued upon transfer to the hospital for two Residents (#16 and #25), out of a sample of 39 residents and two discharge records reviewed. Specifically, the facility failed to provide written notice of the facility's bed-hold policy to the resident/resident representative when transferred to the hospital.

Inspectors wroteBased 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 incident/accident, including an elopement. [...]

Inspectors wroteBased on interviews and records reviewed, for one of three sampled Residents (Resident #1), whose medical 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, he/she had limited attention and concentration, impaired judgement/insight, was assessed and care planned for the need for staff supervision while smoking and using smoking materials, the Facility failed to ensure that 1) staff consistently implemented and followed interventions from his/her Plan of Care related smoking safety with the need for staff supervision while he/she was in possession of smoking materials, and 2) that he/she was accurately assessed by nursing based on criteria identified on the facility elopement risk form related risk factors that needed to [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to prevent the development of a contracture for 1 Resident (#8) and failed to implement a left-hand roll splint for 1 Resident (#1), out of a total sample of 33 residents.

Inspectors wroteBased on observation, record review and interview the facility 1) failed to ensure interventions to prevent a fall for one Resident (#80) were implemented, 2. failed to ensure supervision was provided to prevent one Resident (#78) from leaving the building unattended putting him/her at risk in the community, 3) failed to follow the emergency safety procedures during a fire alarm, and 4) failed to ensure supervision was provided and smoking articles were maintained safely for 2 Resident (#26, and #43 ) out of eleven applicable residents.

Inspectors wrote3. For Resident #1 the facility failed to maintain his/her dignity during the breakfast meal when a Certified Nursing Assistant (CNA) fed Resident #1 standing up, resulting in Resident #1 having to look up at the CNA. Resident #1 was admitted to the facility in June of 2008 and has diagnoses that include but not limited to hemiplegia unspecified affecting left nondominant side, traumatic brain injury, convulsions, contracture left hand, dysphagia, and dementia. Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 5/11/23 indicated Resident #1 scored a 3 out of 15 on the Brief Interview for Mental Status Exam (BIMS) which indicated a severe cognitive impairment and required limited assistance of one person for eating. The surveyor made the following observations: [...]

Inspectors wroteBased on observations and interviews the facility failed to maintain a homelike environment by 1) replacing a broken television for 1 Resident (#20), 2) identifying and replacing a ripped and worn mattress for 1 Resident (#85) and 3) ensuring water temperatures were meeting warm temperature levels in the facility bathroom sinks, out of a total sample of 33 residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility 1) failed to implement the plan of care to off-load heels for 2 Residents (#8 and #47), 2) failed to develop a care plan for an orthotic device for 1 Resident (#54) and 3) failed to implement a care plan to provide padded side rails for 1 Resident (#39), out of a total sample of 33 residents.

Inspectors wrote2b. Resident #1 was admitted to the facility in June 2008 and has diagnoses that include but not limited to hemiplegia unspecified affecting left nondominant side, traumatic brain injury, convulsions, contracture left hand, dementia and dysphagia (difficulty in swallowing.) Review of the Minimum Data Set Assessment (MDS) with an assessment reference date of 5/11/23 indicated Resident #1 scored a 3 out of 15 on the Brief Interview for Mental Status Exam (BIMS) indicating a severe cognitive impairment and requires limited assistance from one person for eating. On 7/18/23 beginning at 8:45 A.M., the surveyor made the following observations: -At 8:45 A.M., a Certified Nursing Assistant (CNA #7) delivered a breakfast tray to Resident #1 consisting of puree food. CNA #7 set up the tray and left the room. [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide an individualized activity program for 4 Residents (#61, #88 and #94) out of a total sample of 33 residents.

Inspectors wroteBased on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 5 of 5 sampled CNAs.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) properly store food items to prevent the risk of foodborne illness in accordance with professional standards for food service safety and 2) failed to ensure staff followed proper sanitation and food handling during meal service to prevent the potential outbreak of foodborne illness.

Inspectors wroteBased on observations and interviews, the facility failed to protect personal healthcare information on 1 out of 3 units.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure two Residents (#72 and 97) were free from restraints out of a total sample of 33 residents. Specifically, the facility failed to assess the use of pillows under the fitted sheet on both sides of the bed as a potential restraint.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to investigate a bruise of unknown origin in a suspicious area for 3 Residents (#30, #99 and #94) out of a total sample of 33 residents.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to follow a physician order for prevention of pressure ulcer for one Resident (#47) out of a total sample of 33 residents.

Inspectors wroteBased on observations, policy review and interviews the facility failed to maintain a suprapubic catheter (a tube that drains urine directly through the abdominal wall) in a manner to reduce infection for one Resident (#97) out of a total 33 sampled residents. Findings Include: Review of facility policy titled 'Catheter Care of Indwelling Urinary' date last revised April,2018, indicated but not limited to the following: Policy: Catheter care will be performed at least daily and as needed (PRN) and in accordance with physician's and/or nursing orders. Guidelines: *Ensure that catheter tubing is secured to the thigh with leg strap and to prevent urinary tract infections caused by urinary reflux, always keep the drainage bag below the level of the residents bladder and off the floor. Position catheter tubing for straight drainage. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to address significant weight loss for 1 Resident (#8) out of a total sample of 33 residents.

Inspectors wroteBased on record review, policy review and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#19) who required renal dialysis (a life sustaining treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) out of a total sample of 33 residents. Specifically, the facility failed to ensure that clamps and pressure dressings were kept with the Resident (#51) for emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine).

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 Resident's (#104) medication regimen was free from unnecessary drugs out of a total sample of 33 Residents.

Inspectors wroteBased on observation, interview and facility policy review the facility failed to ensure that 1. the medication cart was locked and secured on 1 of 3 units observed and 2. medications were properly labeled after opening on 1 of 3 units observed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dental services for 1 Resident (#83) out of a total sample of 33 residents.

Inspectors wroteBased on observation and interview the facility failed to ensure for 1 Resident (#92) out of a total sample of 33 residents, that food provided to the Resident met his/her individual needs. Resident #92 was admitted to the facility in November 2020 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #92 was unable to complete a Brief Interview for Mental Status (BIMS). Further review of the MDS indicated Resident #92 requires physical assistance with eating. On 7/19/23 at 9:18 A.M., Resident #92 was observed walking around the unit unsupervised, eating from a small bag of chips. Resident #92 walked up and down the halls, in a back dining room area and turned back around and walked past several staff members. [...]

Inspectors wroteBased on observation, interview, and meal tray ticket review, the facility failed to provide the dietary preferences for one Resident (#97) out of a total sample of 33 residents.

Inspectors wroteBased on observation, record review and interview the facility 1.) failed to ensure for one Resident (#54) that rehabilitation services were provided in accordance with the physician's order and after Resident #54 was provided a new orthotic, 2.) failed to ensure physical therapy was provided to one Resident (#158) in accordance with the physical therapy treatment plan of care, and 3.) failed to provide Occupational Therapy for one Resident (#97) in accordance with the occupational therapy treatment plan of care, out of a total sample of 33 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure an accurate medical record for 1 Resident (#1), out of a total sample of 33 residents. Specifically, Nursing staff documented that Resident #1 was administered a left-hand roll splint.

Inspectors wroteBased on interview and observations, the facility failed to disinfect shared resident equipment during medication pass.