Norris Square

Penalties

• Nov 3, 2023 — Payment Denial · payment denial 16 days

Inspection findings

1. Dec 10, 2025 Health · 5 findings
   • Not serious Scope/severity D

     F0565 Resident Rights Deficiencies

     Honor the resident's right to organize and participate in resident/family groups in the facility.

     Corrected Jan 30, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Jan 30, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0699 Quality of Life and Care Deficiencies

     Provide care or services that was trauma informed and/or culturally competent.

     Corrected Jan 30, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Feb 2, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Feb 2, 2026 · CMS fire safety

2. Oct 24, 2024 Health · 5 findings
   • Not serious Scope/severity D

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Nov 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Nov 20, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jan 2, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Dec 3, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Dec 3, 2024 · CMS fire safety

3. Nov 3, 2023 Health · 17 findings
   • Not serious Scope/severity D

     F0585 Resident Rights Deficiencies

     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.

     Corrected Nov 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0604 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

     Corrected Nov 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Nov 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Nov 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Nov 28, 2023 · CMS health inspection

   • Serious Scope/severity G

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Nov 28, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Nov 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Nov 28, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Dec 15, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Dec 15, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Dec 15, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Dec 15, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Dec 15, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Dec 15, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Dec 15, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected Dec 15, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Dec 15, 2023 · CMS fire safety

4. Apr 5, 2023 MDH complaint investigation · 1 finding
   • Severity not stated

     H56379840C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

5. Aug 4, 2021 MDH complaint investigation · 1 finding
   • Severity not stated

     H5637015C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

6. Apr 10, 2021 MDH complaint investigation · 4 findings
   • Severity not stated

     H5637010C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H5637011C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H5637012C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H5637013C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

7. Jul 31, 2020 MDH complaint investigation · 2 findings
   • Severity not stated

     H5637005C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H5637007C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

Owners and managers (as published by CMS)

• FLETCHER, JONATHAN — corporate officer, NOT APPLICABLE, since 02/01/2025
• FLETCHER, JONATHAN — corporate director, NOT APPLICABLE, since 02/01/2025
• KISPERT, CHRISTOPHER — operational/managerial control, NOT APPLICABLE, since 08/28/2023
• KISPERT, CHRISTOPHER — adp of the snf, NOT APPLICABLE, since 08/28/2023
• MEYER, MARK — corporate director, NOT APPLICABLE, since 02/09/2016
• MEYER, MARK — corporate officer, NOT APPLICABLE, since 02/09/2016
• MIELKE, JOHN — adp of the snf, NOT APPLICABLE, since 08/29/2019
• MIELKE, JOHN — operational/managerial control, NOT APPLICABLE, since 08/29/2019
• PEDERSON, MARK — corporate director, NOT APPLICABLE, since 01/01/2023
• PEDERSON, MARK — adp of the snf, NOT APPLICABLE, since 01/12/2025
• PETERSON, HEIDI — adp of the snf, NOT APPLICABLE, since 01/01/2023
• PHS MANAGEMENT, LLC — adp of the snf, NOT APPLICABLE, since 04/14/2025
• PHS MANAGEMENT, LLC — operational/managerial control, NOT APPLICABLE, since 08/17/2017
• PRESBYTERIAN HOMES AND SERVICES — 5% or greater direct ownership interest, 100%, since 07/25/2017
• PRESBYTERIAN HOMES HOUSING AND ASSISTED LIVING, INC. — operational/managerial control, NOT APPLICABLE, since 11/18/2024
• TCF INVESTMENTS MANAGEMENT, INC. — 5% or greater mortgage interest, NOT APPLICABLE, since 08/17/2017
• TCF INVESTMENTS MANAGEMENT, INC. — 5% or greater security interest, NOT APPLICABLE, since 08/17/2017