Deficiency Records for Normandy Terrace Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Normandy Terrace Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-05-05 | 2023-06-05 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-05-05 | 2023-06-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-05 | 2023-06-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-05 | 2023-06-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-05 | 2023-06-05 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-05-05 | 2023-06-05 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2023-05-05 | 2023-06-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-05 | 2023-06-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-05 | 2023-06-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-05 | 2023-06-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-05 | 2023-05-06 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-04-06 | 2023-05-05 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-06 | 2023-05-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-06 | 2023-05-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-06 | 2023-05-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-06 | 2023-05-05 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-01-09 | 2023-02-08 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-01-09 | 2023-02-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-09 | 2023-02-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-09 | 2023-02-08 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-04 | 2022-11-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-17 | 2022-09-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-07 | 2022-08-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-09 | 2022-06-30 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-02-18 | 2022-03-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-18 | 2022-03-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-02-18 | 2022-03-31 | N |
| Respond appropriately to all alleged violations. | Health | 2022-02-18 | 2022-03-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-18 | 2022-03-31 | N |
| Provide activities to meet all resident's needs. | Health | 2022-02-18 | 2022-03-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-18 | 2022-03-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-18 | 2022-03-31 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-02-18 | 2022-03-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-18 | 2022-03-31 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-02-18 | 2022-03-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-18 | 2022-03-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-18 | 2022-03-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-18 | 2022-03-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-18 | 2022-03-31 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-02-18 | 2022-03-31 | N |
| Dispose of garbage and refuse properly. | Health | 2022-02-18 | 2022-03-31 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-02-18 | 2022-03-31 | N |
| Keep all essential equipment working safely. | Health | 2022-02-18 | 2022-03-31 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-02-18 | 2022-03-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-18 | 2022-03-31 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-02-24 | 2022-03-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-24 | 2022-03-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-24 | 2022-03-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-01 | 2022-03-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-01 | 2022-03-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-01 | 2022-03-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-01 | 2022-03-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-01 | 2022-03-14 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-02-24 | 2022-02-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-09 | 2021-12-30 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-12-09 | 2021-12-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-03 | 2021-12-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-03 | 2021-12-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-03 | 2021-12-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-03 | 2021-11-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-09-17 | 2021-10-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-17 | 2021-10-29 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-17 | 2021-10-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-17 | 2021-10-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-17 | 2021-10-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-27 | 2021-08-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-17 | 2021-07-08 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-03-26 | 2021-04-26 | Y |
| Provide or obtain dental services for each resident. | Health | 2021-03-26 | 2021-04-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-26 | 2021-04-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-26 | 2021-04-26 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-03-26 | 2021-04-26 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-03-26 | 2021-04-26 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-03-24 | 2021-04-26 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-03-24 | 2021-04-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-03-24 | 2021-04-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-03-24 | 2021-04-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-24 | 2021-04-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-24 | 2021-04-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-03-24 | 2021-04-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-03-24 | 2021-04-26 | N |
