Normandy Terrace Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Aug 13, 2024

  38511 Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse, neglect and misappropriation of property for 2 of 6 residents (Residents #2 and #3) reviewed for abuse, in that: 1. The facility failed to protect Resident #2 from physical abuse when Resident #1 grabbed, scratched and hit Resident #2 during a smoke break on [DATE]. The facility failed to respond to develop a plan of care, behavior monitoring, interventions or train staff on behaviors to prevent further abuse. 2. […]

• Immediate jeopardy, patternF656Aug 13, 2024

  38511 Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 4 residents (Residents #1, #2, and #3) reviewed for care plans, in that: 1. Facility failed to develop a person-centered care plan with interventions that addressed Resident #1's diagnoses of mental illness including depression, schizophrenia, dementia or antisocial personality disorder, and behaviors which included stealing, agitation, and aggression. 2. […]

• Immediate jeopardy, isolatedF678Jul 17, 2026

  Based on interview and record review, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 3 residents (Resident #2) reviewed for death. The facility failed to provide immediate basic life support interventions for Resident #2 upon finding Resident #2 unresponsive on [DATE], and Resident #2 was declared deceased on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:33 PM. […]

• Immediate jeopardy, isolatedF684Jul 17, 2026

  Based on observation, interview and record review, the facility failed to, based on the comprehensive assessment of a resident, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to identify and address Resident #1's fall with injury appropriately, leaving Resident #1 with a fractured hip for over 24 hours without treatment. An Immediate Jeopardy (IJ) situation was Identified on 07/13/2026. […]

• Immediate jeopardy, isolatedF689Aug 18, 2025

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 1 residents (Resident #1) reviewed for accidents and supervision in that: The facility failed to supervise Resident #1 who eloped from the facility on 08/16/25 and was gone from the facility for more than nine hours and found in a closed car and had sustained a heat stroke. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 08/16/2025 and ended on 08/16/2025. The facility had corrected the non-compliance before the survey began on 08/17/2025. […]