Norwood Towers Post-Acute

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #44) of three residents reviewed for medication administration. The facility census was 101 residents.

Inspectors wroteBased on review of the medical record, staff and resident interviews, and policy review, the facility failed to accommodate the residents who wanted showers versus bed baths. This affected one (Resident #40) of three residents reviewed for bathing. The facility census was 108. Review of the medical record for Resident #40 revealed an admission date of 08/26/25. Diagnoses included chronic kidney disease, peripheral vascular disease (PVD), and mood disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of nine. This resident was assessed to require substantial assistance with toileting and dressing, bathing and transfers. [...]

Inspectors wroteBased on review of the medical record, staff interviews, and policy review, the facility failed to ensure physicians/providers were notified of a significant change in resident status and failed to notify the physicians/providers when a resident was moved to the secured Memory Care Unit. This affected one (Resident #47) of three residents reviewed for significant changes. The facility census was 108. Review of the medical record for Resident #47 revealed an admission date of 01/13/22. Diagnoses included chronic obstructive pulmonary disease (COPD), type I diabetes mellitus (DM I), and paranoid schizophrenia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. [...]

Inspectors wroteBased on review of the medical record, staff interviews, and facility policy, the facility failed to ensure residents were free from abuse. This affected two Residents (#65 and #111) of four residents reviewed for abuse. The facility census was 108. 1) Review of the medical record for Resident #111 revealed an admission date of 10/10/25 with a discharge date of 02/03/26. Diagnoses included malignant neoplasm of brain, hypertension, and metabolic encephalopathy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. Review of the progress note dated 12/30/25 at 8:00 A.M. revealed Resident #111 had facial trauma per the staff from a physical disturbance between him and Resident #65, and then they were separated immediately. [...]

Inspectors wroteBased on medical record review, observations, staff and resident interviews, and policy review, the facility failed to ensure residents were free from involuntary seclusion. This affected one (Resident #47) of three resident reviewed for smoking. The facility census was 108. Review of the medical record for Resident#47 revealed an admission date of 01/13/22. Diagnoses included chronic obstructive pulmonary disease (COPD), type I diabetes mellitus (DM I), and paranoid schizophrenia. Review of the smoking observation assessment dated [DATE] revealed Resident #47 was an independent smoker with no cognitive impairment. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11. [...]

Inspectors wroteBased on review of the medical record, interviews, and policy review, the facility failed to implement their abuse policy when an allegation of abuse was reported. This affected two Residents (#65 and #111) of the four residents reviewed for abuse. The facility census was 108 1) Review of the medical record for Resident #111 revealed an admission date of 10/10/25 with a discharge date of 02/03/26. Diagnoses included malignant neoplasm of brain, hypertension, and metabolic encephalopathy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This resident was assessed to require partial assistance with eating, dependent on toileting, bathing, and dressing, and setup for transfers. Review of the progress note dated 12/30/25 at 8:00 A.M. [...]

Inspectors wroteBased on review of the medical record, interviews, and policy review, the facility failed to report alleged abuse to the state agency. This affected two Residents (#65 and #111) of four residents reviewed for abuse. The facility census was 108. 1) Review of the medical record for Resident #111 revealed an admission date of 10/10/25 with a discharge date of 02/03/26. Diagnoses included malignant neoplasm of brain, hypertension, and metabolic encephalopathy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This resident was assessed to require partial assistance with eating, dependent on toileting, bathing, and dressing, and setup for transfers. Review of the progress note dated 12/30/25 at 8:00 A.M. [...]

Inspectors wroteBased on review of the medical record, interviews, and facility policy, the facility failed to thoroughly investigate alleged abuse. This affected two (#65 and #111) of four residents reviewed for abuse. The facility census was 108. 1) Review of the medical record for Resident #111 revealed an admission date of 10/10/25 with a discharge date of 02/03/26. Diagnoses included malignant neoplasm of brain, hypertension, and metabolic encephalopathy. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #111 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of zero. This resident was assessed to require partial assistance with eating, dependent on toileting, bathing, and dressing, and setup for transfers. Review of the progress note dated 12/30/25 at 8:00 A.M. [...]

Inspectors wroteBased on medical record review, observation, resident and staff interview, hospice staff interview, review of the hospice record, review of the controlled drug receipt/record/disposition form, review of the text message correspondence, and policy review, the facility failed to ensure a resident with chronic pain syndrome received as needed medication for breakthrough pain. This resulted in Actual Harm, when staff failed to ensure Resident #08 received as needed (PRN) pain medication when she reported severe pain. This affected one (#08) of three residents reviewed for pain. The census was 110.

Inspectors wroteBased on record review, staff and resident interviews, observation, and review of facility policy, the facility failed to provide information on the grievance process and how to file a grievance. This affected three (Residents #37, #66 and #106) of three residents reviewed on how to file a grievance and had the potential to affect all residents residing in the facility. The facility census was 111. Based on record review, staff and resident interview, observation, and policy review, the facility failed to provide information on the grievance process and how to file a grievance. This affected three (Residents #37, #66 and #106) of three residents reviewed on how to file a grievance. This had the potential to affect all residents residing in the facility. The facility census was 111.

Inspectors wroteBased on review of the medical record, staff and resident interviews, observations, and policy review, the facility failed to ensure the residents were made aware of what they were going to be served for meals. This had the potential to affect 108 of the 111 residents in the facility who received food from the kitchen. The facility identified three residents (#9, #17 and #89) who did not receive food from the kitchen. The facility census was 111. Based on review of the medical record, staff and resident interviews, observations, and policy review, the facility failed to ensure the residents were made aware of what they were going to be served for meals. This affected three (#28, #93, and #117) out of five residents reviewed for food and nutrition. This had the potential to affect 108 out of the 111 residents in the facility who received food from the kitchen. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure food was stored in a manner to prevent the potential spread of foodborne illness. This had the potential to affect 108 out of 111 residents in the facility who received food from the kitchen. The facility identified three residents (#9, #17 and #89) who did not receive food from the kitchen. The facility census was 111.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to provide a homelike environment. This affected seven (#114, #47, #25, #50, #17, #71, and #73) out of seven residents reviewed for the environment. In addition, the facility failed to ensure the elevator was clean and had appropriate lighting. This had the potential to affect any resident who used the elevator. Additionally, the facility failed to ensure the memory care unit (MCU) was free from odors. This had the potential to affect all residents who resided in rooms 251, 252, 253, 254, 255, 256, 257, 258, and 259. The facility census was 111.

Inspectors wroteBased on record review, observation, staff and resident interviews and review of facility policy, the facility failed to provide privacy and dignity for three (Residents #39, #94, and #100) out of seven residents reviewed for dignity. The facility census was 111. Based on medical record review, observation, staff and resident interview and policy review, the facility failed to provide privacy and dignity for three (Residents #39, #94, and #100) out of seven residents reviewed for dignity. The facility census was 111. Findings Included: 1. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses of asthma, anorexia, major depressive disorder, and dementia. [...]

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to notify the physician, registered dietician, and resident's representative when Resident #24 had a change of condition. This affected one resident (#24) out of three residents reviewed for change of condition. The facility census was 111. Based on record review, staff interview, and policy review, the facility failed to notify the physician, the registered dietician, and the resident's representative when Resident #24 had a change of condition. This affected one resident (#24) out of three residents reviewed for change of condition. The facility census was 111.

Inspectors wroteBased on medical record review, Minimum Data Set (MDS) review, staff interview, review of the Resident Assessment Instrument (RAI) manual, and policy review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed when a resident received a new diagnosis of bipolar disorder and when a resident had a severe weight loss. This affected two (Residents #3 and #24) of three residents reviewed for a significant change in condition. The facility census he was 111. Based on medical record review, staff interview, review of the Resident Assessment Instrument (RAI) manual, and policy review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed when a resident received a new diagnosis of bipolar disorder and when a resident had a severe weight loss. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents with newly evident or possible serious mental disorders were referred for level II resident review upon a significant change in status assessment. This affected one (Resident #3) of four residents reviewed for pre-admission screening and resident review (PASARR). The facility census was 111. Based on record review and staff interview, the facility failed to ensure residents with newly evident or possible serious mental disorders were referred for level II resident review upon a significant change in status assessment. This affected one (Resident #3) of four residents reviewed for pre-admission screening and resident review (PASARR). The facility census was 111.

Inspectors wroteBased on medical record review, Pre-admission Screening and Resident Review (PASARR) review, staff interviews, and policy review, the facility failed to make notification to the state mental health agency for a significant change in mental health diagnosis for one (Resident #3) of three residents reviewed for notification of change process. The facility census was 111. Based on medical record review, Pre-admission Screening and Resident Review (PASARR) review, staff interviews, and policy review, the facility failed to make notification to the state mental health agency for a significant change in mental health diagnosis for one (Resident #3) of three residents reviewed for notification of change process. The facility census was 111.

Inspectors wroteBased on medical record review, staff interview, resident interview, and policy review, the facility failed to ensure residents were provided with necessary assistance for Activities of Daily Living (ADL's). This affected three (Residents #17, #73 and #76) of five residents reviewed for ADL's. The facility census was 111. Based on medical record review, staff interview, resident interview, observation, and policy review, the facility failed to ensure residents were provided with necessary assistance for Activities of Daily Living (ADL's). This affected three (Residents #17, #73 and #76) of five residents reviewed for ADL's. The facility census was 111.

Inspectors wroteBased on observations, medical record review, staff and resident interviews, and policy review, the facility failed to ensure residents were safely smoking on the facility property. This affected two (#47 and #103) of two residents reviewed for smoking. The facility identified there were fifteen residents who required assistance with smoking. The facility census was 111.

Inspectors wroteBased on record review, observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure the resident's medications were properly stored. This affected one (Resident #100) of 37 residents reviewed for medication storage. The facility census was 111.

Inspectors wroteBased on medical record review, observation, interview, and facility policy review, the facility failed to ensure the call light was within reach for three (#22, #39, and #84) out of 25 residents reviewed. The facility census was 111. Findings Included: 1. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, seizures, epilepsy, hemiplegia, and dementia. Review of Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed that Resident #22 had severe cognitive impairment and required setup or clean-up assistance for eating, oral care, bathing, dressing upper body, dressing lower body, putting on and off feet, and personal hygiene. [...]

Inspectors wroteBased on observations, resident and staff interviews, medical record review, and review of the facility policy, the facility failed to ensure medications were not left at the bedside in a secured memory care unit. This affected one (Resident #9) of two residents reviewed for accidents. The facility identified 27 residents (#6, #10, #12, #13, #17, #20, #21, #23, #26, #30, #33, #37, #40, #44, #45, #52, #58, #66, #67, #72, #73, #81, #92, #93, #97, #99, and #100) who were cognitively impaired and independently mobile on the secured unit. The facility census was 110.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure medications were stored in a proper and safe manner. This had the potential to affect all residents in the facility except the 40 residents residing on the secure unit. The facility census was 110.

Inspectors wroteBased on observations, resident and staff interviews, medical record review, and policy review, the facility failed to ensure a resident who was dependent on staff for personal hygiene received adequate nail care. This affected one (Resident #78) of six residents reviewed for activities of daily living (ADLs). The facility census was 110.

Inspectors wroteBased on medical record review and staff interview, the facility failed to timely act on pharmacy recommendations. This affected two (Residents #16 and #32) of five residents reviewed for unnecessary medications. The facility census was 110.

Inspectors wroteBased on observation, medical record review, staff interview, review of facility policy, and review of Centers for Disease Control (CDC) guidelines, the facility failed to ensure newly admitted residents were quarantined when indicated and proper precautions implemented, as well as not ensuring personal protective equipment (PPE) was readily available. Additionally, the facility failed to ensure residents were encouraged to remain socially distant during activities and smoking to prevent the potential spread of Covid-19. This had the potential to affect all 75 residents of the facility.

Inspectors wroteBased on review of Resident Council Meeting notes, resident interview, review of response forms, and staff interview, the facility failed to provide specific and appropriate resolution to resident concerns expressed during the meetings. The had the potential to affect 12 residents (#63, #41, #70, #54, #122, #30, #34, #60, #44, #23, #35 and #41) who attended the meetings in 2021. The facility census was 75 residents.

Inspectors wroteBased on review of the facility's surety bond, review of the resident personal fund trust account balance, and staff interview, the facility failed to ensure the amount of the resident funds surety bond was sufficient to assure the security of the amount of the resident's funds deposited with the facility. This had the potential to affect all 54 residents (#35, #59, #03, #17, #21, #45, #48, #53, #05, #54, #47, #04, #38, #32, #44, #46, #50, #06, #27, #63, #57, #40, #25, #60, #26, #58, #61, #10, #41, #09, #30, #19, #16, #62, #68, #28, #64, #07, #322, #18, #66, #55, #42, #67, #29, #69, #33, #11, #13, #20, #08, #71, #31, and #02) who had authorized the facility to manage their personal funds. The facility census was 75.

Inspectors wroteBased on observation, staff interview, resident interview, and review of facility policy, the facility failed to provide each resident with housekeeping and/or maintenance services necessary to maintain a sanitary and orderly environment to ensure protection of one resident's personal belongings from loss. This affected 12 residents (#7, #68, #59, #30, #27, #28, #67, #29, #47, #14, #71, and #32) of 12 residents reviewed for environment. The facility census was 75.

Inspectors wroteBased on medical record reviews, staff interview, resident interview, and facility policy review, the facility failed to provide bed hold notices for residents sent to the hospital. This affected five residents (#6, #7, #75, #122, and #322) of seven reviewed for bed hold notifications. The facility census was 75.

Inspectors wroteBased on medical record review, review of Pharmacy Consultation Reports, and staff interview, the facility failed to act upon pharmacy recommendations for the gradual dose reduction (GDR) and discontinuation of anxiety medications. This affected three residents (#16, #32, and #42) of five reviewed for unnecessary medications. The facility census was 75.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure when a resident formulated an advanced directive it was accurately recorded in all locations of the medical record to ensure the resident's wishes would be followed as directed in the event of an emergency. This affected one resident (#68) of one reviewed for Advanced Directives. The facility census was 75.

Inspectors wroteBased on medical record review, observation, staff and resident interview, the facility failed to develop and/or implement a comprehensive plan of care for each resident for assessed problems/needs relating to urinary incontinence, activities of daily living (ADLs), contractures, and the need to reside on a secured unit. This affected three residents (#68, #7, #29) of 31 reviewed for care plans. The facility census was 75.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure a resident with a limited range of motion received appropriate treatment and services, including splinting, to improve and/or prevent further decline in range of motion (ROM). This affected one resident (#7) of one reviewed for ROM. The facility census was 75.

Inspectors wroteBased on review of the personnel files and staff interview, the facility failed to provide annual performance evaluations and 12 hours of inservice education for two State Tested Nursing Assistants (STNAs) of four reviewed. The facility census was 75.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure a resident received the necessary behavioral health care and services to maintain their highest practicable mental and psychosocial well being. This affected one resident (#68) of one reviewed for behavioral health. The facility census was 75.