A list of the most recent deficiencies for Norris Square. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-01 | 2023-12-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-11-03 | 2023-11-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-11-03 | 2023-11-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-03 | 2023-11-28 | N |
| Provide activities to meet all resident's needs. | Health | 2023-11-03 | 2023-11-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-03 | 2023-11-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-03 | 2023-11-28 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-11-03 | 2023-11-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-03 | 2023-11-28 | Y |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-01-05 | 2023-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-05 | 2023-02-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-23 | 2021-10-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-23 | 2021-10-28 | N |
| 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. | Health | 2021-09-23 | 2021-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-23 | 2021-10-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-22 | 2021-10-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-22 | 2021-10-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-22 | 2021-10-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-09-23 | 2021-10-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-17 | 2021-10-01 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-22 | 2021-09-23 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-09-22 | 2021-09-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-09-22 | 2021-09-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-22 | 2021-09-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-22 | 2021-09-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-20 | 2021-08-24 | Y |
