Normandy Nursing Center

In the surveyor’s words

From the most serious findings on record at Normandy Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 20, 2023

  Based on observation, interview and record review, the facility failed to ensure the safety of one of two sampled residents (Resident #1) when a cognitively impaired resident, whose diagnoses included schizophrenia and vascular dementia, left the building unaccompanied. Staff last saw the resident on 10/12/23 at approximately 11:00 P.M. The resident left pillows and clothing in a form under the blankets. Staff did not visualize the resident. Staff did not administer ordered morning medications or provide breakfast. On 10/13/23 at approximately 12:30 P.M., a nurse pulled the covers back, and saw the resident was not there. The resident was found on 10/13/23 at a homeless shelter. He/She tried to find a bus station, but became confused and went to the shelter. The census was 85. […]

• Immediate jeopardy, isolatedF600Nov 14, 2022

  Based on interview and record review, the facility failed to keep residents free from physical abuse when Resident #2 and Resident #3 had a verbal altercation which escalated into a physical altercation during a smoke break. Two staff were present during the incident, which lasted approximately five minutes, and neither staff intervened. Resident #3 sustained an orbital (bones around the eyeball) fracture. The facility also failed to keep residents free from physical abuse when Nurse A poured a pot of cold coffee on Resident #1 when he/she became agitated and aggressive toward Nurse A. Nurse D was present and witnessed the incident but did not intervene. Nurse A returned to work the next day for an entire shift and worked on the same hall as Resident #1. The resident sample was 11. […]

• Actual harm, isolatedF689Jun 30, 2026

  Based on interview and record review, the facility failed to ensure staff provided adequate supervision and assistance to prevent accidents for one resident, (Resident #2) with a history of falls, when staff left the resident unattended on the toilet. The resident attempted to transfer him/herself from the toilet to his/her wheelchair without assistance and fell. When the nurse assessed the resident, he/she guarded his/her right hip and complained of pain. X-ray results showed the resident sustained a fractured right hip. In addition, the facility failed to address falls on the care plan. The sample was four. The census was 95.Review of the facility's Fall Management policy, dated 02/28/23, showed:-Policy: To provide an environment free of accident hazards. […]

• Actual harm, isolatedF600May 16, 2025

  Based on observation, interview and record review, the facility failed to ensure 8 sampled residents, who were involved in resident-to-resident incidents were free from physical abuse (Residents #27 and #37, Residents #39 and #65, Residents #4 and #1 and Residents #86 and #49). The resident-to-resident altercations resulted in injuries. The sample was 19. The census was 95. Review of the Abuse Prevention policy, revised 10/21/22, showed: -Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, and other staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individual; -Definitions: -Abuse:… […]

• Actual harm, isolatedF684May 31, 2022

  See Event ID MQ6T12. Based on observation, interview and record review, the facility failed to ensure staff followed physician orders by failing to administer accu-checks (blood sugar checks) and insulin, and by failing to notify the physician when blood glucose levels exceeded parameters and when a resident refused accu-checks and/or insulin. The facility identified 10 residents receiving insulin. Of those 10, two had blood glucose levels that exceeded physician orders/and or nursing standards of practice, in accordance with the Assistant Director of Nursing's (ADON) expectations for blood glucose parameters (Residents #20 and #19). Resident #20 was transferred to the hospital with a diagnosis of hyperglycemia (high blood sugar). […]