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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Normandy Manor Of Rocky River during CMS and state inspections, most recent first.
The facility failed to ensure call lights were within reach for two residents and did not respond to call lights in a timely manner for eighteen residents. Observations and interviews revealed that staff often turned off call lights without providing immediate assistance, leading to prolonged discomfort for residents. The call light audit confirmed multiple instances of delayed responses, and facility policies on call light accessibility were not followed.
The facility failed to prevent neglect as staff were found sleeping on duty, affecting residents' care. A resident reported staff sleeping outside his room, and another mentioned staff sleeping in cars, causing care delays. An LPN witnessed a CNA asleep, and despite the facility's policy against such behavior, it was not effectively enforced, leading to non-compliance.
A resident with severe cognitive impairment experienced a significant decline in meal consumption, consuming only 25% of meals and refusing several entirely. Despite this, the facility failed to notify the resident's physician or NP in a timely manner, as required by policy. Interviews confirmed the delay in communication, leading to a deficiency finding.
A long-term care facility failed to implement Enhanced Barrier Precautions for a resident with a feeding tube, as an LPN did not wear a gown during care. Additionally, two STNAs did not perform hand hygiene after providing personal care to residents. These deficiencies were identified through observations and interviews, revealing lapses in infection prevention practices.
The facility failed to maintain a clean and sanitary dumpster area, potentially affecting all 126 residents. Observations revealed open sliding doors on dumpsters, garbage and debris on the ground, and an unpleasant odor. The Dietary Director confirmed the area was not maintained properly, despite shared responsibility with grounds and kitchen staff. Facility policy required dumpsters to have tight-fitting lids and be covered at all times.
The facility did not develop baseline care plans within 48 hours for two residents upon admission, as required by policy. One resident had severe cognitive impairment and was dependent on staff for ADLs, while the other had intact cognition but also required staff assistance. The absence of these care plans was confirmed by an MDS nurse.
A resident receiving enteral nutrition was found to have water at their bedside despite an NPO order, and their PEG tube dressing was not changed daily as required. Staff interviews confirmed these oversights, indicating a failure to follow physician's orders for the resident's care.
Deficiency in Call Light Accessibility and Response Time
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents and did not respond to call lights in a timely manner for eighteen residents. This deficiency was identified through observations, interviews, and reviews of resident records, facility policies, and call light audits. The facility's census was 136, indicating that this issue had the potential to affect all residents. Resident #65, who was admitted with diagnoses including sepsis and atherosclerotic heart disease, was observed to be uncomfortable and sliding down in her wheelchair. Despite activating her call light, assistance was delayed for approximately one hour. Interviews revealed that staff turned off the call light without providing immediate assistance, and the resident's discomfort persisted until the transfer to bed was completed. The call light audit report confirmed multiple instances of delayed responses to call lights for various residents, with wait times ranging from 20 to 39 minutes. Additionally, Resident #62's call light was found on the floor, out of reach, preventing her from calling for assistance. Similarly, Resident #31's call light was observed hanging low and out of reach. Staff interviews confirmed these findings, and the facility's policy on call light accessibility and timely response was not adhered to. The resident council meeting minutes and concern log also documented complaints about long call light response times, particularly on weekends.
Neglect Due to Staff Sleeping on Duty
Penalty
Summary
The facility failed to prevent neglect of resident care due to staff sleeping while on duty, affecting residents on the 500-Hall and 800-Hall. A resident raised concerns during a council meeting about staff sleeping outside his room with blankets. The facility's employee handbook prohibits sleeping on duty, and disciplinary actions are outlined for such behavior. Despite this, a CNA was terminated after being caught sleeping on duty, following three previous disciplinary actions related to work performance. Another resident reported that staff slept during the night shift, sometimes in their cars, leading to delays in care. An LPN confirmed witnessing a CNA asleep on the 800-Hall and expressed frustration with the working conditions. The facility's policy on abuse, neglect, and exploitation, which includes preventing neglect by ensuring necessary goods and services are provided to residents, was not implemented effectively. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's policies and procedures designed to protect residents from neglect.
Failure to Notify Physician of Decreased Oral Intake
Penalty
Summary
The facility failed to timely notify a resident's physician or nurse practitioner regarding the resident's decreased oral intake. The resident, who had severe cognitive impairment and was on a no concentrated carbohydrates diet, showed a significant decline in meal consumption over several days. Specifically, the resident consumed only 25% of meals on multiple occasions and refused several meals entirely, including all meals on one day and breakfast the following day. Despite these changes, there was no documentation indicating that the physician or nurse practitioner was informed of the resident's decreased oral intake. The resident's medical record showed that the resident was admitted with diagnoses including cerebral infarction, unspecified dementia, hypothyroidism, and major depressive disorder. The resident's weight remained relatively stable, but the documentation revealed a pattern of decreased food and fluid intake. On one occasion, the resident refused all meals and fluids for an entire day, and on another, consumed only a small portion of meals. Despite these concerning signs, the facility did not notify the resident's physician or nurse practitioner until several days later. Interviews with facility staff confirmed that the nurse practitioner was not informed of the resident's condition until days after the significant decrease in oral intake. The facility's policy on notification of changes requires prompt communication with the resident's physician and representative when there is a change in condition. However, this policy was not followed, resulting in a deficiency related to the failure to notify the appropriate medical personnel in a timely manner.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to consistently implement Enhanced Barrier Precautions (EBP) for a resident with medically complex conditions, including a feeding tube. The resident was dependent on staff for personal care and had a physician's order requiring the use of gloves and gowns during specific care activities. However, during an observation, an LPN did not wear an isolation gown while performing a dressing change on the resident's g-tube site, despite the presence of a sign indicating EBP and an isolation cart with personal protective equipment near the room entrance. The LPN acknowledged the oversight, attributing it to a misunderstanding of the requirement. Additionally, the facility did not ensure proper hand hygiene was performed by staff following resident care. In one instance, an STNA provided perineal care to a resident without washing hands or using hand sanitizer afterward, even after handling items in the resident's room. The STNA confirmed the lapse in hand hygiene during an interview. Similarly, another STNA failed to perform hand hygiene after providing incontinence care to a different resident and before entering another resident's room. The facility's policies on Enhanced Barrier Precautions and Perineal Care were reviewed, revealing that the facility was expected to implement these precautions to prevent the transmission of multi-drug resistant organisms. The policies required staff to perform hand hygiene before and after providing care, which was not adhered to in the observed instances. These deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in infection prevention and control practices.
Improper Garbage Disposal and Unsanitary Dumpster Area
Penalty
Summary
The facility failed to maintain a clean and sanitary dumpster area, which had the potential to affect all 126 residents residing in the facility. During an observation conducted with the Dietary Director (DD) of the facility, it was noted that the dumpster area behind the kitchen contained two dumpsters with sliding doors left open. A significant amount of garbage and debris was observed on the ground outside the dumpsters and in the surrounding brush, accompanied by an unpleasant odor emanating from the area. An interview with the DD confirmed that maintaining the cleanliness of the dumpster area was a shared responsibility between the grounds and kitchen staff. The DD acknowledged that the area was not maintained in a clean and sanitary manner. A review of the facility's undated policy on Garbage Removal and Dumpster revealed that the dumpsters were required to have tight-fitting lids and sliding doors, which should be kept covered at all times. This deficiency was investigated under Complaint Number OH00155054.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop baseline care plans for two residents within 48 hours of their admission, as required by their policy. Resident #120, who was admitted with diagnoses including sepsis due to streptococcus pneumoniae, aphasia, and dysarthria, had severely impaired cognition and was dependent on staff for activities of daily living (ADLs). Despite these needs, the medical record for Resident #120 did not include a baseline care plan, a fact confirmed by MDS Nurse #508 during an interview. Similarly, Resident #67, admitted with conditions such as left non-dominant sided hemiplegia and hemiparesis, cerebral infarction, and gastrostomy status, also did not have a baseline care plan in their medical record. This resident had intact cognition but was dependent on staff for ADLs. The absence of a baseline care plan for Resident #67 was also confirmed by MDS Nurse #508. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission and that a written summary be provided to the resident or their representative, which was not adhered to in these cases.
Failure to Follow Physician's Orders for Enteral Nutrition Care
Penalty
Summary
The facility failed to adhere to physician's orders regarding the care of a resident with a percutaneous endoscopic gastrostomy (PEG) tube, leading to a deficiency in care. Resident #67, who was admitted with multiple diagnoses including hemiplegia, cerebral infarction, dysphagia, and gastrostomy status, was identified as receiving enteral nutrition. The physician's orders specified that the resident should receive nothing by mouth (NPO) and that the PEG tube site should be cleaned and covered with a dry dressing daily. However, observations revealed that the resident had two Styrofoam cups of water on his bedside tray, contrary to the NPO order, and the dressing on the PEG tube site was not changed daily as required, with the last change noted two days prior. Interviews with the resident and staff confirmed these findings. The resident reported that staff regularly left water on his tray table despite the NPO order and acknowledged that the PEG tube dressing was not changed daily. An LPN confirmed the presence of water at the resident's bedside and acknowledged the oversight, instructing a nursing assistant to remove the water. The LPN also confirmed that the dressing was not changed daily as per the physician's orders. The facility's policy on the care and treatment of feeding tubes, which mandates adherence to physician's orders, was not followed in this instance.
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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.
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Nursing homes near Rocky River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Welsh Home The | 1.6 mi | ★★★★★ | 0 | 0 |
| O'neill Healthcare Fairview Park | 2.6 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Westlake | 3 mi | ★★★★★ | 8 | 0 |
| Huntington Woods Care & Rehab Center | 3 mi | ★★★★★ | 0 | 0 |
| Lutheran Home | 3.1 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 July 2026) and official state health department websites.