Health inspection·August 22, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident interview, staff interview, medical record review and review of facility policy, the facility failed to ensure Enhanced Barrier Precautions (EBP) were consistently implemented for Resident #67. This affected one (#67) of one resident reviewed for EPB. The facility identified 27 additional residents (#2, #9, #12, #14, #16, #27, #32, #33, #36, #44, #50, #54, #59, #60, #63, #76, #79, #80, #82, #101, #105, #107, #108, #118, #123, #126, and #127) on EBP. Additionally, the facility failed to ensure hand hygiene was performed following resident care. This affected two (#73 and #85) of two residents reviewed for personal care. The facility census was 127. Residents Affected - Many Findings include: Record review for Resident #67 revealed an admission date of 05/31/24. Diagnoses included gastrostomy status. Review of the admission Minimum Data Set (MDS) assessment, dated 06/07/24, revealed Resident #67 was cognitively intact. Resident #67 was dependent for toileting, bathing, personal hygiene and was always incontinent of bowel and bladder. Resident #67 had medically complex conditions and had a feeding tube. Review of a physician order, dated 06/01/24, revealed EBP - gloves and gown to be worn when providing: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and/or wound care (any skin opening requiring a dressing). Review of a physician order dated 07/23/24 revealed an order to cleanse gastrostomy (g)-tube site with normal saline (NS), pat dry and cover with dry split gauze daily and as needed. Review of the care plan, 06/03/24, revealed Resident #67 was on EBP related to a feeding tube and included gloves and gown to be worn when providing the following: dressing, bathing/showering, transferring, hygiene assistance, changing linens, incontinence care, toileting and device care or use. Observation on 08/22/24 at 9:00 A.M. of g-tube site care and treatment with Licensed Practical Nurse (LPN) #272 revealed Resident #67 had a sign near the entrance door to the room revealing the resident was on EBP. There was an isolation cart with personal protective equipment (PPE) near the entrance of the door. Continued observation revealed LPN #272 gathered the supplies to complete the dressing change to Resident #67's g-tube site. LPN #272 entered Resident #67's room without donning an isolation gown. LPN #272 proceeded to remove the old dressing, cleanse the g-tube site, applied new dressing and washed her hands. Concurrent interview with LPN #272 verified Resident #67 was on EBP and confirmed she did not wear an isolation gown while providing care, including the dressing change to (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 08/22/2024 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)