Health inspection·December 19, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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 12/14/23 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 10/01/23 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 12/03/23. There was a pie with no name or date and another pizza with no name or date. On the door of the refrigerator, a sign in bright pink stated, RESIDENT FOOD ITEMS ONLY. All items must be dated. Discard all items after 72 hours once opened. An additional sign in bright orange dated 05/02/19 read, ATTENTION ALL STAFF AND FAMILY MEMBERS: All food and beverages must be labeled with [the] resident's name and dated. Food and beverages will be thrown away three days from the date that is marked on the item. • In the west nutrition room, a putrid odor was present immediately upon opening the door. No thermometer was present in the refrigerator. Two undated and unlabeled takeout bags were noted that had a strong odor. There was a container with Resident #105's name and no date. A bottle of expired French dressing dated 12/06/23 was in the door of the refrigerator. • In the memory care refrigerator, the bottom shelf was stained and there was not a thermometer. There was a container of expired milk dated 12/02/23 and an opened milk that expired 12/13/23. There was a can of whipped cream with the date 06/05/21 in the door of the refrigerator and an undated bag of shredded lettuce. Interviews with DM #263 on 12/14/23 starting at 10:23 A.M. verified the observations at the time of (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365926 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365926 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Normandy Manor of Rocky River 22709 Lake Rd Rocky River, OH 44116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)