Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Normandy Nursing Center during CMS and state inspections, most recent first.
A resident with dementia, weakness, hallucinations, and a history of falls was left unattended on the toilet and tried to transfer to a wheelchair without help, falling onto the right side and later found to have a right femoral neck fracture. The resident had a prior fall as well, but the care plan did not document the fall history, fall risk status, or fall interventions. Staff interviews confirmed residents should not be left alone in the bathroom, and the resident was resistive to care and dependent on staff for transfers and toileting.
Failure to notify a resident representative of a change in condition: A resident with severe cognitive impairment had an unwitnessed fall, complained of pain, refused ordered x-rays, and later was found to have a fractured R femoral neck before being sent to the hospital. The record did not document that the POA was notified of the x-ray refusal, the fracture results, or the transfer, despite facility policy requiring notification of the resident representative after accidents/incidents and significant changes in condition.
The facility's dietary department failed to maintain sanitary conditions, with soot and grime on kitchen equipment, debris on floors, and an empty soap dispenser. Staff interviews revealed confusion over cleaning responsibilities and schedules, leading to unsanitary conditions. The facility's Nutritional Sanitation policy and cleaning checklists were not followed.
The facility failed to maintain a clean and functional environment, as evidenced by locked and unclean bathrooms, incomplete shower repairs, and unclean common areas. A resident's bathroom was locked for a month due to maintenance issues, forcing them to use a common bathroom, leading to accidents. Another resident's shower was incomplete for two months, causing discomfort with using the community shower. A third resident's shower had a separated cove base, and common areas were found unclean with offensive odors.
The facility failed to maintain an effective pest control program, leading to bed bug infestations in the rooms of two residents. One resident, diagnosed with bipolar disorder and schizophrenia, was observed squishing a bed bug, while another, with anemia and PTSD, was unaware of the infestation despite visible evidence. The pest control company noted structural issues and improper handling of mattress covers, and the Administrator acknowledged challenges in eradicating the pests.
A resident was physically abused by another resident, resulting in a scratch under the eye, due to provocation. The facility's abuse policy was not effectively implemented, as the incident was not documented, and staff were unaware until informed by a surveyor. Known behaviors of both residents were not addressed in care plans, indicating a deficiency in abuse prevention and response.
A facility failed to administer a prescribed antipsychotic medication, Abilify, to a resident with schizophrenia, leading to an incident where the resident hit another resident. The medication order was documented but not initiated by the ADON, despite the resident's care plan requiring its administration. Interviews confirmed the oversight, and the resident was subsequently moved and monitored closely.
Failure to Supervise Toileting and Update Fall Care Plan
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent an accident for a resident with a history of falls and significant cognitive and functional impairment. The resident had diagnoses including Alzheimer's disease, dementia with psychotic disturbance, history of stroke, muscle weakness, delusional disorder, depression, difficulty walking, hallucinations, history of falling, and communication deficit. The resident's fall risk evaluation identified intermittent confusion, wheelchair use, balance problems, multiple predisposed diseases, and that the resident was at risk for falls. The resident's care plan in use during the survey did not document the resident's fall history, fall risk status, identified risk factors, or fall interventions. On 04/26/26, staff left the resident unattended on the toilet. The resident attempted to transfer from the toilet to the wheelchair without assistance and fell onto the right side. After the fall, the resident had an abrasion to the right elbow and right buttock, guarded the right leg, and complained of pain. The nurse could not assess range of motion because of guarding and refusal. The physician, resident representative, and DON were notified, and x-rays of the right hip, femur, and knee were ordered. The resident was later found to have a nondisplaced impaction fracture of the right femoral neck. The record also showed the resident had a prior fall after admission, including being found on the floor beside the bed with a hematoma to the right side of the head, but the care plan still did not reflect the resident's falls or updated interventions. During interviews, staff stated residents should never be left unattended in the bathroom, and the Administrator said she would have preferred the aide to stay with the resident during toileting. The ADON reported that the resident was resistive to care and had a previous fall, and the NP stated the resident was a fall risk and would not have expected staff to get the resident up to toilet him/her.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative after a change in condition involving an unwitnessed fall and subsequent fracture. Resident #2 had severe cognitive impairment and diagnoses including Alzheimer's disease, dementia with psychotic disturbance, history of stroke, muscle weakness, delusional disorder, depression, difficulty walking, hallucinations, history of falling, and communication deficit. After the resident's unwitnessed fall, the resident complained of pain and the physician ordered x-rays. The resident refused the x-rays the next day, and the x-rays were reordered two days later. The x-rays showed a nondisplaced impaction fracture of the right femoral neck, and the resident was later sent to the hospital for evaluation. The record did not show documentation that the resident's POA was notified of the x-ray refusal, the x-ray results, or the transfer to the hospital. The facility's policy required the attending physician and resident representative to be notified of a change in condition, including accidents/incidents and significant changes in medical baseline, and to document notification of the resident representative in the IDT notes. During interviews, an LPN stated the POA was onsite and was told about the x-ray refusal, but this was not documented. The ADON stated a risk management note showed the POA was notified of the x-ray results and fracture, but she could not locate that note. The Administrator stated she would have expected nursing staff to notify the POA of the resident's change in condition.
Sanitation Deficiencies in Dietary Department
Penalty
Summary
The facility failed to maintain sanitary practices and conditions within the dietary department, leading to potential contamination of food during storage, preparation, and distribution. Observations revealed soot buildup on the steam table, debris and grime on shelves and knobs, and unclean cabinet drawers containing utensils with old torn paper and dried grime. Interviews with staff indicated a lack of awareness and adherence to cleaning schedules, with some staff unaware of the existence of certain drawers and unsure of the cleaning frequency. In the dish room, broken bait traps, trash, and grime were found on the floor, along with dishes filled with dried food and debris. The walls had green corrosion and brown splatters, and there were missing ceiling tiles. Staff interviews revealed a lack of clear responsibility for cleaning, with some staff believing that whoever noticed dirt should clean it, while others were unsure of their specific duties. Additionally, the soap dispenser at a handwashing sink was found empty, with conflicting reports on who was responsible for refilling it. The Dietary Manager and Administrator both expressed expectations for daily, weekly, and monthly cleaning schedules to be followed, and for soap dispensers to be filled, but these expectations were not met. The facility's Nutritional Sanitation policy and cleaning checklists were not adhered to, leading to unsanitary conditions in the kitchen.
Facility Fails to Maintain Clean and Functional Environment for Residents
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. Resident #5's bathroom was locked for a month due to a maintenance issue with the toilet, forcing the resident to use a common bathroom, which led to accidents due to the unavailability of the bathroom when needed. The resident's shower was found to be unclean, with feces and hair present, and the bathroom was not cleaned before being locked. The Maintenance Director acknowledged the issue but could not provide documentation for ordered parts, and the Administrator was unaware of the bathroom's condition. Resident #4's shower was incomplete, with unfinished walls and a disconnected shower hose, rendering it unusable for two months. The resident expressed discomfort with using the community shower due to privacy and hygiene concerns. The Maintenance Director admitted the delay in completing the shower repairs and was unable to provide documentation for ordered materials. The Administrator was unaware of the ongoing issue with the resident's shower. Resident #1's shower had a cove base that was separated from the wall, and the resident was using an inappropriate chair as a shower chair. The Maintenance Director was unaware of the cove base issue, and the Administrator acknowledged similar issues elsewhere in the facility. Additionally, common areas, including a community bathroom and utility room, were found to be unclean, with offensive odors and lack of soap. The Housekeeping Supervisor and Administrator both expected staff to follow cleaning schedules, but the deficiencies indicated a failure to maintain cleanliness and timely repairs.
Bed Bug Infestation Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in bed bug infestations in the rooms of two residents. Resident #8, who is cognitively intact and diagnosed with bipolar disorder and schizophrenia, was observed squishing a bed bug with his bare fingers, indicating an active infestation. The resident reported that a privacy curtain in his room had been infested with bed bugs, which was removed, washed, and returned. Despite receiving a new mattress and cover, the resident expressed distress over the bed bug issue, which he felt was affecting his mental well-being. Resident #10, also cognitively intact and diagnosed with anemia, anxiety disorder, depression, and PTSD, was observed sitting on a bed frame with dried blood and smashed bed bugs. A live bed bug was seen crawling on the bed frame. The resident, who shared a room with others, was unaware of the infestation. The Housekeeping Supervisor indicated that housekeeping was responsible for cleaning bed frames, but the Maintenance Director was unaware of the bed bugs until informed by the Administrator. The Maintenance Director then took steps to address the issue, including bagging the resident's clothes and planning to treat the room. Interviews with the pest control company revealed that the facility received semi-monthly services, but recommendations were not always followed. The pest control technician noted structural issues and improper handling of mattress covers, which were expensive and meant to contain bed bugs. The technician highlighted the need for strict procedures and isolation of infested rooms. The Administrator acknowledged the difficulty in eradicating bed bugs, citing new residents as a source of reintroduction. Despite efforts such as using alcohol spray and heat treatment for soft items, the facility struggled to maintain control over the infestation.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident was hit in the face by another resident, resulting in a scratch under the left eye. The incident occurred when the resident was in bed, and the aggressor was reportedly provoked by comments about their mother. The affected resident expressed fear of returning to their room, indicating a lack of immediate intervention to ensure their safety and well-being. The facility's abuse policy outlines the commitment to protect residents from abuse by anyone, including other residents. However, the incident was not documented in the medical records of either resident involved, and staff members, including a Licensed Practical Nurse and a Certified Nurse Aide, were unaware of the altercation until informed by the surveyor. This lack of awareness and documentation suggests a failure in communication and monitoring within the facility. Interviews with staff revealed that the resident who was hit had a history of agitating other residents, and the aggressor had previous issues with roommates. Despite these known behaviors, there were no documented interventions in the care plan to address the potential for resident-to-resident altercations. The facility's response to the incident was delayed, as the Regional Nurse and Administrator only became aware of the situation after being informed by the surveyor, highlighting a deficiency in the facility's abuse prevention and response protocols.
Failure to Administer Prescribed Antipsychotic Medication
Penalty
Summary
The facility failed to follow a physician's order to administer an antipsychotic medication, Abilify, to a resident diagnosed with schizophrenia and experiencing delusional behaviors. The psychiatric Nurse Practitioner (NP) prescribed the medication to manage the resident's paranoia and delusions. However, the Assistant Director of Nursing (ADON) documented the order but did not initiate it, leading to the medication not being administered. This oversight was discovered after the resident exhibited aggressive behavior by hitting another resident, which resulted in the resident being moved to a different unit and placed on one-on-one monitoring. The resident's care plan included the administration of antipsychotic medications as ordered by the physician, with monitoring for side effects and effectiveness. Despite this, the medication was not given, and the resident's behavior escalated, leading to an incident. Interviews with the ADON, NP, and Director of Nursing (DON) confirmed that the order should have been initiated and followed as prescribed. The NP noted that if the medication had been administered, the resident might not have exhibited the aggressive behavior.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| U-city Forest Manor | 1.1 mi | ★★★★★ | 23 | 0 |
| Monarch Springs Wellness & Rehabilitation | 1.9 mi | ★★★★★ | 29 | 0 |
| Amberwood Estates Nursing And Rehabilitation | 2.3 mi | ★★★★★ | 36 | 0 |
| Heritage Care Center | 2.5 mi | ★★★★★ | 4 | 1 |
| Delhaven Manor | 2.8 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.