Inspection visit
Inspection
Citations
17 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F585 - Grievances
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.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F679 - Activities
Provide activities to meet all resident's needs.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the November 3, 2023 survey of NORRIS SQUARE?
This was a inspection survey of NORRIS SQUARE on November 3, 2023. The surveyor cited 17 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at NORRIS SQUARE on November 3, 2023?
Yes, 17 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grie..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.