Health inspection·July 11, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure baseline care plans were developed and failed to ensure summaries of the baseline care plan were provided to the residents and/or their representatives. This affected two (Residents #120 and #67) out two residents who were reviewed for baseline care plans. The facility census was 126 residents. Findings include: 1. Review of the medical record for Resident #120 revealed admission date of 05/25/24 and diagnoses including sepsis due to streptococcus pneumoniae, aphasia, and dysarthria. Review of the admission Minimum Data Set (MDS) assessment for Resident #120 dated 06/01/24 revealed the resident had severely impaired cognition and was dependent on staff for activities of daily living (ADLs.) Review of the medical record for Resident #120 revealed it did not include a baseline care plan. Interview on 07/11/24 at 1:04 P.M. with MDS Nurse #508 confirmed the facility had not completed a baseline care plan for Resident #120. 2. Review of the medical record for Resident #67 revealed admission date of 05/31/24 and diagnoses including left non-dominant sided hemiplegia and hemiparesis, cerebral infarction, difficulty walking, gastrostomy status, aphasia, and enterocolitis due to clostridium difficile. Review of the admission MDS assessment dated [DATE] revealed Resident #67 had intact cognition and was dependent on staff for ADLs. Review of the medical record for Resident #67 revealed it did not include a baseline care plan. Interview on 07/11/24 at 1:08 P.M. with MDS Nurse #508 confirmed the facility had not completed a baseline care plan for Resident #67. Review of the facility policy titled Baseline Care Plan revealed a baseline care plan would be developed within 48 hours of a resident's admission which would include minimum care planning information. A written summary of the baseline care plan would be provided to the resident and representative in a language that the resident/representative would understand. 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 3 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 07/11/2024 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)