Normandy Manor of Rocky River

In the surveyor’s words

From the most serious findings on record at Normandy Manor of Rocky River, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 12, 2024

  Based on medical record reviews, observations, family interview, staff interviews, and policy review the facility failed to ensure adequate fall interventions were in place to promote resident safety and prevent falls. Actual harm occurred on 12/05/23 when Resident #120, who was severely cognitively impaired and assessed at risk for falls, sustained an unwitnessed fall from a bed that was not in low position resulting in increased pain and hospitalization for traumatic sacral fractures with presacral edema and lumbar one and four compression fractures. The resident was not a candidate for invasive procedures and returned to the facility with hospice consultation orders. This affected three residents (#2, #88 and #120) of three residents reviewed for falls. […]

• No harm, potential for more than minimal, widespreadF880Aug 22, 2024

  Based on observation, resident interview, staff interview, medical record review and review of facility policy, the facility failed to ensure Enhanced Barrier Precautions (EBP) were consistently implemented for Resident #67. This affected one (#67) of one resident reviewed for EPB. The facility identified 27 additional residents (#2, #9, #12, #14, #16, #27, #32, #33, #36, #44, #50, #54, #59, #60, #63, #76, #79, #80, #82, #101, #105, #107, #108, #118, #123, #126, and #127) on EBP. Additionally, the facility failed to ensure hand hygiene was performed following resident care. This affected two (#73 and #85) of two residents reviewed for personal care. The facility census was 127. Findings include: Record review for Resident #67 revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF814Jul 11, 2024

  Based on observation, staff interview, and review of the facility policy, the facility failed to maintain a clean and sanitary dumpster area. This had the potential to affect all of the residents residing in the facility. The facility census was 126 residents. Findings include: Observation on 07/08/24 at 9:02 A.M. with Dietary Director (DD) #470 of facility dumpster area behind the kitchen revealed there were two dumpsters. The sliding doors on the sides of both dumpsters were open with a significant amount of garbage and debris on the ground outside the dumpsters and in the surrounding brush. There was an unpleasant odor emanating from the dumpster. Interview on 07/08/24 at 9:03 A.M. […]

• No harm, potential for more than minimal, widespreadF583Feb 12, 2024

  Based on observation, record review, resident interview, Ombudsman interview, and staff interviews, the facility failed to deliver all of residents mail to them and or their authorized representative. The facility also failed to provide residents mail to them unopened. This affected five (#10, #36, #97, #122, and #123) of five reviewed for mail and had the potential to affect all residents. The facility census was 117. Findings include: 1. Review for Resident #97's medical record revealed an admitted [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #97 revealed Resident #97 was cognitively intact. Interview on 02/06/24 at 3:04 P.M., with Resident #97 revealed she received her mail the previous day delivered by an Activities Assistant #262. […]

• No harm, potential for more than minimal, widespreadF812Dec 19, 2023

  Based on observation, interview and policy review, the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 118 residents receiving food from the facility's kitchen as Resident #13 was ordered nothing-by-mouth (NPO). The facility census was 119 residents. Findings include: Observation of the unit refrigerators on [DATE] starting at 10:23 A.M. with Dietary Manager (DM) #263 revealed the following areas of concern: In the east dining room refrigerator, a bag with Resident #17's name on it had a sell by date of [DATE] and contained bread and soup. There was a container with Resident #23's name on it that had no date and contained salad and pita bread. There was a pizza box labeled with Resident #4's name and the date [DATE]. […]