Rocky River, OH

Normandy Manor Of Rocky River

3-star overall rating with 2-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

22709 Lake Rd, Rocky River, OH

(440) 333-5400

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

150

Certified beds

Average residents

130

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1993-06-25

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.43

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.82

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.24

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.49

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.25

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.05

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.25

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.44

CMS adjusted RN staffing hours

Adjusted total hours

3.57

CMS adjusted total nurse staffing hours

Case-mix index

1.34

Higher values indicate more complex resident acuity

RN turnover

46%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

49%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,731

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

25.83

Composite VBP score used to determine payment impact.

Payment multiplier

0.9839

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.29

Baseline 21.67% · Performance 19.91% · Measure score 3.29 · Achievement 3.28 · Improvement 3.29

Healthcare-associated infections

5.52

Baseline 10.04% · Performance 7.00% · Measure score 5.52 · Achievement 2.78 · Improvement 5.52

Total nurse turnover

Performance 61.94% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

1.52

Baseline 3.50 hours · Performance 3.51 hours · Measure score 1.52 · Achievement 1.52 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.64%	10.72% 0.1 pts better	No Different than the National Rate · Eligible stays 97 · Observed rate 9.28% · Lower 95% interval 7.07%
Discharge to community	53.73%	50.57% 3.2 pts better	No Different than the National Rate · Eligible stays 92 · Observed rate 43.48% · Lower 95% interval 42.82%
Medicare spending per beneficiary	0.88	1.02 0.1 pts better
Drug regimen review with follow-up	96.67%	95.27% 1.4 pts better	Numerator 58 · Denominator 60
Falls with major injury	5%	0.77% 4.2 pts worse	Numerator 3 · Denominator 60
Discharge self-care score	47.73%	53.69% 6 pts worse	Numerator 21 · Denominator 44
Discharge mobility score	31.82%	50.94% 19.1 pts worse	Numerator 14 · Denominator 44
Pressure ulcers or injuries, new or worsened	1.67%	2.29% 0.6 pts better	Numerator 1 · Denominator 60 · Adjusted rate 1.48%
Healthcare-associated infections requiring hospitalization	7%	7.12% 0.1 pts better	No Different than the National Rate · Eligible stays 56 · Observed rate 5.36% · Lower 95% interval 3.77%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 158
Staff flu vaccination coverage	29.23%	42% 12.8 pts worse	Numerator 38 · Denominator 130
Discharge function score	54.55%	56.45% 1.9 pts worse	Numerator 24 · Denominator 44
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 21 · Denominator 21
Resident COVID-19 vaccinations up to date	10%	25.2% 15.2 pts worse	Numerator 3 · Denominator 30

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.7	1.8 0.1 pts better	1.9 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.4	1.8 0.4 pts better	1.8 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.1%	92.4% 3.7 pts better	93.4% 2.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 93.7% · Q2 95.7% · Q3 97.5% · Q4 97.5% · 4Q avg 96.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.4%	94.5% 3.9 pts better	95.5% 2.9 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4%
Percentage of long-stay residents experiencing one or more falls with major injury	5.4%	3.3% 2.1 pts worse	3.3% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 6.0% · Q3 4.2% · Q4 5.8% · 4Q avg 5.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	26.1% 26.1 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	6.9%	6.2% 0.7 pts worse	5.4% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 7.3% · Q3 4.3% · Q4 5.3% · 4Q avg 6.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	37.1%	25.4% 11.7 pts worse	19.6% 17.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 40.6% · Q3 39.4% · Q4 36.8% · 4Q avg 37.1%
Percentage of long-stay residents who received an antipsychotic medication	12.7%	11.5% 1.2 pts worse	16.7% 4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 18.6% · Q3 11.4% · Q4 5.6% · 4Q avg 12.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	3.7%	7.7% 4 pts better	16.3% 12.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 7.6% · Q3 2.4% · Q4 2.2% · 4Q avg 3.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	2.3%	6.2% 3.9 pts better	14.9% 12.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 5.6% · Q3 1.1% · Q4 1.1% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.2% 0.2 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.2%	0.5% 0.3 pts better	1.7% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.6%	21.7% 4.9 pts worse	19.8% 6.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 29.5% · Q3 33.2% · Q4 21.3% · 4Q avg 26.6%
Percentage of long-stay residents with pressure ulcers	2.3%	3.7% 1.4 pts better	5.1% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.5% · Q3 1.3% · Q4 1.7% · 4Q avg 2.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	88.9%	78.1% 10.8 pts better	81.7% 7.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 69.7% · Q2 89.8% · Q3 100.0% · Q4 100.0% · 4Q avg 88.9%
Percentage of short-stay residents who had an outpatient emergency department visit	10.1%	12.5% 2.4 pts better	12.0% 1.9 pts better	Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 10.4% · Expected 11.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.2% 1.2 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	88.4%	75.6% 12.8 pts better	79.7% 8.7 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 88.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.0%	25.1% 1.1 pts better	23.9% 0.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 22.9% · Expected 22.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-07-11 · Fire 2024-07-11

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

8 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2022-04-15 · Fire 2022-04-15

17 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 3 Health 2019-04-25 · Fire 2019-04-25

15 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-07-11

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2024-08-22

F · Potential for more than minimal harm 2024-07-11

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-09-11

F · Potential for more than minimal harm 2024-07-11

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-08-22

F · Potential for more than minimal harm 2024-07-11

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-08-22

F · Potential for more than minimal harm 2024-07-11

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-08-22

F · Potential for more than minimal harm 2024-07-11

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-08-22

E · Potential for more than minimal harm 2024-07-11

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-08-22

E · Potential for more than minimal harm 2024-07-11

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-08-22

F · Potential for more than minimal harm 2022-04-15

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-05-15

E · Potential for more than minimal harm 2022-04-15

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-05-15

F · Potential for more than minimal harm 2019-04-25

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-06-12

F · Potential for more than minimal harm 2019-04-25

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2019-06-12

F · Potential for more than minimal harm 2019-04-25

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2019-06-12

E · Potential for more than minimal harm 2019-04-25

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2019-06-12

E · Potential for more than minimal harm 2019-04-25

K347 · Smoke Deficiencies

Fire Safety

Properly provide smoke detection systems in areas open to corridors.

Corrected 2019-06-12

E · Potential for more than minimal harm 2019-04-25

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-06-12

E · Potential for more than minimal harm 2019-04-25

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2019-06-12

E · Potential for more than minimal harm 2019-04-25

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2019-06-12

E · Potential for more than minimal harm 2019-04-25

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-06-12

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-11-06

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-11-27

E · Potential for more than minimal harm 2024-11-06

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-11-27

D · Potential for more than minimal harm 2024-11-06

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-11-27

F · Potential for more than minimal harm 2024-08-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-11

F · Potential for more than minimal harm 2024-07-11

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2024-08-22

E · Potential for more than minimal harm 2024-07-11

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2024-09-11

D · Potential for more than minimal harm 2024-07-11

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2024-08-22

G · Actual harm 2024-02-12

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-03-06

F · Potential for more than minimal harm 2024-02-12

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-03-06

D · Potential for more than minimal harm 2024-02-12

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-03-06

D · Potential for more than minimal harm 2024-02-12

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-03-06

F · Potential for more than minimal harm 2023-12-19

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-12-22

F · Potential for more than minimal harm 2023-07-27

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2023-08-17

D · Potential for more than minimal harm 2023-07-27

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-08-17

D · Potential for more than minimal harm 2023-07-27

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-08-17

F · Potential for more than minimal harm 2022-04-15

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-05-15

F · Potential for more than minimal harm 2022-04-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-05-15

E · Potential for more than minimal harm 2022-04-15

F761 · Pharmacy Service Deficiencies

Health

Corrected 2022-05-15

E · Potential for more than minimal harm 2022-04-15

F803 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2022-05-15