Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Norfolk Health Care Center during CMS and state inspections, most recent first.
A resident with stroke, chronic systolic HF, left-sided hemiparesis, aphasia, and moderate cognitive impairment (BIMS 7) was allowed to leave on an LOA with a person identified as a cousin, after being signed out and assisted by a CNA who was not trained on the LOA process. Staff, including an LPN and the Manager on Duty, believed the resident was going to a cookout and would return later that day, but the resident did not return and remained away for about three days without the knowledge of nursing staff or family. The resident’s daughter learned he was missing only when contacted by staff, and a missing person report was filed with local law enforcement. Although facility policy required prompt reporting of unusual incidents and submission of a 5‑day investigative report to the state agency, no such reports were made; instead, the state agency received an anonymous complaint and later a call from the resident. The facility’s internal investigation was incomplete and did not include all relevant statements or a full chronology of events.
Staff failed to follow and competently implement the LOA process, allowing a cognitively impaired, functionally dependent resident with multiple comorbidities to leave with a cousin for several days without the knowledge of nursing staff or family. A CNA who had not been trained on LOA assisted the resident in leaving, and an LPN relied on second-hand information that the resident would return later that evening, without confirming or documenting the required LOA details or medications. The resident did not return as expected, and his absence was only recognized the next day when an LPN noted missed medications and contacted the resident’s daughter, who reported that the family had not taken him. The facility’s LOA policy requirements for nurse notification, estimated time of return, medication provision, and documentation were not met, and no required report of the incident was submitted to the state agency.
Staff failed to follow written menus and individual meal tickets for several residents, including one with stroke and heart failure on a fluid‑restricted diet who received a biscuit instead of the ordered cornbread, another with a tracheostomy and diabetes on a mechanical advanced/chopped diet who was served an unchopped pork loin and a biscuit instead of the ordered dinner roll, and a resident with dysphagia and cerebral palsy who did not receive the cornbread portion listed on the meal ticket despite expressing a desire for more food to gain weight. The Dietary Manager reported that ordered bread items were unavailable due to missed food deliveries and that substitutions were not updated in the menu/meal ticket software.
A resident with multiple comorbidities and intact cognition was discharged home with physician orders for a bedside commode, front‑wheeled walker, and HH services including nursing and PT. The resident reported that the ordered DME did not arrive for several days and HH services did not start for about a week, leaving her to use a bedpan despite limited mobility and reporting increased weakness and flaccidity in one leg. The Director of Social Services and Director of Rehabilitation confirmed the delays in DME delivery and HH initiation, and the Administrator acknowledged the time frames were not acceptable. Discharge planning notes documented the resident’s complaints about missing DME, the inability of a PCA company to provide services, and subsequent contacts with the DME supplier and multiple HH agencies, confirming that the resident’s ordered equipment and HH services were not provided in a timely manner after discharge.
Multiple residents did not receive beverages with their lunch meals as listed on menus, meal tickets, or physician orders. Cognitively intact and impaired residents with conditions such as dysphagia, cerebral palsy, malnutrition, stroke, renal failure, heart failure, tracheostomy, diabetes, and PVD were served full meals without the hot coffee, tea, milk, or measured fluid-restricted beverages specified for them. In some cases, a resident verbally requested the missing beverage from an LPN, who did not return with it, while CNAs relied on bedside water pitchers instead of following the meal ticket. The Dietary Manager reported that beverages had been removed from trays due to spills and sent separately, and also noted a software error listing milk at lunch, but was unaware that residents were not consistently receiving the required 8 oz and 6 oz beverages with meals.
Staff failed to post required enhanced barrier precaution (EHB) signage for a resident with a tracheostomy and feeding tube who had an active physician order for EHB every shift and documented cognitive impairment. During multiple days of surveyor observation, no EHB sign was present on the resident’s door or wall, even though EHB signs were posted for other residents throughout the facility. A CNA and an RN confirmed that residents with trachs, feeding tubes, PICC lines, or dialysis should be on EHB precautions and that staff had been in-serviced to follow posted signs for high-contact care activities. The RN acknowledged that the resident should have been on EHB precautions and attributed the missing signage to the resident’s recent room change, during which new signage was not put up.
Facility staff failed to maintain a sanitary, clean, and comfortable environment on both the 200-unit and 400 floor. On the 200-unit, corridors were littered with debris and uncleaned spills, rooms had dirty floors, missing trash can liners, used gloves on the floor, heavily soiled and damaged fall mats, and clutter including broken items and dust under beds; one resident also reported that another resident’s TV remote controlled his television. An EVS staff member stated she mops around items on the floor rather than moving them and was unable to fully clean some fall mats, though she reported these issues to her supervisor. On the 400 floor, surveyors noted recurring strong urine odors and dirty, debris-covered floors on some tours, contrasted with periods when the area appeared clean and odor-free, with only a few housekeepers present when odors were again detected; facility leadership acknowledged environmental concerns.
The facility failed to ensure RN coverage and competent tracheostomy care on a specialized unit, resulting in missed medication doses, inadequate assessment, and improper interventions by LPNs for residents with complex needs. These deficiencies led to critical events, including two resident deaths and one resident found deceased without RN oversight, with staff reporting inadequate training and support.
Failure to Provide Beverages Listed on Meal Tickets: During lunch observations, several residents did not receive beverages listed on the menu or on their personalized meal tickets. A resident with dysphagia and cerebral palsy, a resident with moderate protein calorie malnutrition, and two other residents with stroke, renal failure, heart failure, tracheostomy, diabetes, and PVD were served meals without the ordered or selected drinks. Staff, including the DON, ADON, LPN, and DM, acknowledged that the meal tickets should have been followed and that the beverages should have been provided.
Delayed DME and HH Services After Discharge: A resident with heart disease, ESRD, morbid obesity, and muscle weakness was discharged home with orders for a BSC, FWW, and HH nursing/PT, but the DME was not delivered until several days later and HH did not start for about a week. The resident said she had to use a bedpan for days, and the DON/IDT confirmed the delays were not typical or acceptable.
Meals Served Did Not Match Menu and Meal Tickets: A facility failed to serve meals in accordance with the menu and personal meal tickets for three residents. One resident with dysphagia and cerebral palsy did not receive the listed cornbread and reported wanting extra food to gain weight; two other residents were also served biscuits instead of the ordered bread item, and one resident on a mechanically advanced/chopped diet received a whole slice of pork instead of chopped meat. The DM said some items were unavailable because deliveries did not occur as expected, and the substitutions were not updated on the menu or meal tickets due to software issues.
A resident with a trach and feeding tube did not have EHB precaution signage posted on the room door or wall, despite an active order for enhanced precautions. Surveyors observed the missing signage during multiple rounds, and staff acknowledged the resident should have been on EHB precautions; an RN stated the sign was not put up after the resident was moved to another room.
Sanitary and Comfortable Environment Not Maintained: Staff failed to keep multiple unit areas clean and odor-free. In the 200-unit, corridors had debris, dark spill-like spots, cluttered medical equipment, dirty floors, a glove on the floor, soiled bedside mats, and clutter under a resident bed; another room was dark, smelly, and had a dirty, smelly toilet. EVS said she mopped around items because she did not know what they were and could not fully clean some fall mats. On the 400 floor, surveyors noted strong urine odors and dirt/debris on some tours, while another tour found the area clean with housekeeping staff present.
A resident with intact cognitive abilities and at risk for pressure ulcers reported waiting for hours for incontinence care, preventing participation in activities. The care plan required timely cleaning and moisture barrier application, but staff failed to adhere, as observed by a heavily saturated brief. A CNA acknowledged the delay, and an LPN considered the resident okay since the urine was contained, leading to the deficiency.
Failure to Implement Abuse and Unusual Occurrence Reporting Policies for Unauthorized LOA
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse and unusual occurrence reporting policies when a cognitively impaired resident left the facility on a leave of absence (LOA) and remained away for approximately three days without the knowledge of nursing staff or the resident’s family. The resident had diagnoses including stroke, hypertension, chronic systolic heart failure, left-sided hemiparesis, and aphasia, and a recent MDS with a BIMS score of 7/15 indicating moderate cognitive impairment, with a need for assistance with all ADLs. At the time of the incident, the resident was his own decision maker, as the POA documents were not executed until after his return. On the day of the incident, the resident left the facility around 2:00 p.m. with a person identified as a cousin, who signed the resident out on the LOA sheet; staff, including an LPN and the Manager on Duty, understood that the resident was going to a cookout and would return later that evening. The report states that a CNA, who was not trained on the LOA process, helped the resident leave, which the Administrator later identified as an error. The resident did not return that evening as expected. The following day, an LPN became concerned when the resident was not back in the building to receive medications and called the resident’s daughter, who then learned for the first time that the resident was missing and that no family member had removed him. The facility’s abuse/neglect/misappropriation/crime policy required reporting unusual incidents or occurrences to the State Survey Agency, including events likely to result in legal action or involving law enforcement, and specified time frames for initial reporting and submission of investigative findings. Despite the resident being gone for approximately 72 hours and a missing person report being filed with local police, the facility did not submit an initial report or a 5‑day follow‑up report to the state agency as mandated by its abuse policy. The state agency instead received an anonymous complaint two days after the incident, with an addendum indicating that the resident himself later contacted the state agency after learning he had been deemed a missing person and expressed a desire to discharge and make his own decisions. The facility’s internal investigation was incomplete at the time of review; it lacked statements from residents and all involved individuals and did not clearly document the chronology of events leading to the incident. The Administrator and DON reported no additional information when interviewed, and the failure to follow the abuse and unusual occurrence reporting policy, along with allowing an untrained CNA to assist with the LOA, constituted the core deficiency.
Failure to Ensure Competent LOA Process Resulting in Unmonitored Resident Absence
Penalty
Summary
Facility staff failed to maintain competency in the nursing aide proficiency related to leaves of absence (LOA), resulting in a resident leaving the facility for approximately three days without the knowledge of family or nursing staff. The resident involved had a history of stroke, hypertension, chronic systolic heart failure, left-sided hemiparesis, and aphasia, and had a BIMS score of 7/15 indicating moderate cognitive impairment. He required assistance with all activities of daily living and, prior to the incident, was his own decision maker, as the power of attorney (POA) documents were not executed until after his return. On the day of the incident, the resident left the facility at approximately 2:00 p.m. with a person identified as a cousin, who signed the resident out on the facility’s LOA sign-out sheet. CNA staff assisted the resident in leaving, despite not having been trained on the LOA process. The Manager on Duty observed the resident leaving with the family member and was told by both the cousin and the resident that he had been signed out and would be going to a cookout and returning later that evening. LPN staff were informed, via another CNA, that the resident would return around 7:00 p.m., and this information was passed in shift report, but no further verification or follow-up occurred when the resident did not return as expected. The facility’s LOA policy required that the patient or responsible party notify a licensed nurse prior to leaving, provide an estimated time of return, receive medications, and have the LOA documented in the medical record, with additional notification to administrative staff if the resident would not return the same day. In this case, the resident left with a family member without medications and without a documented plan consistent with policy requirements. The resident’s departure was not recognized as a problem until the following day when an LPN noted that he had not returned to receive medications and contacted the resident’s daughter, who reported that the family had not removed him and was unaware of his whereabouts. No initial or 5‑day follow‑up report of the incident was submitted by the facility to the state agency as required by law.
Failure to Follow Menus and Meal Tickets for Diet Orders and Portions
Penalty
Summary
Facility staff failed to serve meals according to the written menu and individual meal tickets for multiple residents. One resident with stroke, renal failure, and heart failure, who had moderately impaired cognition and required setup assistance for eating, was observed at lunch receiving roasted pork with gravy, beets, mashed potatoes, a biscuit, and an apple dessert. The resident’s menu and personal meal ticket specified that cornbread, not a biscuit, should be served, and the meal ticket also documented a regular diet with a fluid restriction of 1200 milliliters per day and one 8‑ounce beverage. The Dietary Manager later stated that cornbread was not available because the food delivery did not occur as scheduled and that the substitute item was not updated on the menu or meal tickets due to software difficulties. Another resident with tracheostomy, diabetes, peripheral vascular disease, and heart failure, who had intact cognition and required setup assistance with eating, was ordered a mechanical advanced/chopped diabetic diet. The meal ticket for this resident specified chopped roasted pork loin, diced beets, mashed potatoes, a dinner roll, margarine, apple crisp, 2% milk, and hot coffee or tea. During observation of the lunch meal, the resident was served a whole slice of roasted pork with gravy instead of chopped pork, and a biscuit instead of the dinner roll listed on the ticket. The Dietary Manager acknowledged that the pork loin not being chopped was an error and again reported that dinner rolls were unavailable due to a missed food delivery and that the substitute item was not reflected on the menu or meal tickets. A third resident with dysphagia, mechanically altered PO intake, and cerebral palsy, who had intact cognition and was able to use utensils to eat once the meal was placed before him, reported wanting more food to gain weight and stated he was not receiving extra portions despite asking. Observation of this resident’s lunch tray showed roasted pork loin, pork gravy, diced Harvard beets, creamy mashed potatoes, a biscuit, and apple crisp. The resident’s meal ticket listed the same items but included cornbread, which was not present on the tray. The resident commented that the tray “comes like that sometimes” but reiterated his desire to gain weight. The Dietary Manager later stated there was no cornbread mix available, so a biscuit was served instead.
Failure to Ensure Timely Provision of DME and Home Health Services After Discharge
Penalty
Summary
Facility staff failed to ensure timely provision of ordered durable medical equipment (DME) and home health (HH) services for one resident who was discharged home. The resident, cognitively intact per a discharge MDS BIMS score of 15, had diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, morbid obesity due to excess calories, end stage renal disease, and muscle weakness. Upon discharge home, physician orders were in place for a bedside commode and a front‑wheeled walker to be delivered to the resident’s home, as well as HH services including nursing and physical therapy. The resident reported that these DME items were not delivered until several days after discharge and that HH services did not begin until approximately one week after arrival home. During this period, the resident stated she had to use a bedpan for four days and, due to limited mobility, this was very difficult on her body and mental state, and she reported that her body became weaker and one leg became flaccid. Interviews with facility staff corroborated the delays in DME and HH service initiation. The Director of Social Services confirmed that the resident was discharged home and that the bedside commode and front‑wheeled walker were not delivered until several days later, and that HH services did not begin until about a week after discharge, acknowledging this was an issue and not typical. The Director of Rehabilitation stated she had provided a bedpan prior to discharge because the bedside commode would not be at the home when the resident arrived and later went to the resident’s home to set up the bedside commode after the DME provider did not do so. The Administrator stated it was not acceptable that the DME was delivered and HH services started after such delays. Discharge planning notes documented the resident’s calls reporting that DME had not been delivered and that a personal care aide company could not cover services, as well as subsequent contacts with the DME provider and multiple HH agencies, confirming that the ordered equipment and HH services were not in place in a timely manner following discharge.
Failure to Provide Ordered and Menu-Listed Beverages With Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide beverages as listed on menus, as ordered, or per resident preferences during meals for multiple residents. For one resident with dysphagia, mechanically altered PO intake, and cerebral palsy, the lunch meal ticket specified hot coffee or hot tea, but no beverage was served with the meal. The resident, who had intact cognitive abilities and could use utensils to bring food and liquid to the mouth, reported not receiving anything to drink with lunch and indicated he would drink from his personal water bottle instead. Facility leadership later acknowledged that the meal ticket should have been followed and that beverages should have been available. Another cognitively intact resident with a diagnosis including moderate protein calorie malnutrition reported poor service from nursing and dietary staff. At lunch, the resident’s meal ticket listed hot tea or coffee, but no beverage was present on the tray other than what was already on the bedside table. The resident was heard asking an LPN for his tea or coffee; the LPN shrugged, left the room, and did not return with a beverage. The Dietary Manager later stated that the residents should have received their beverages. Two additional residents did not receive beverages in accordance with the menu and their personalized meal tickets. One resident with stroke, renal failure, and heart failure, and with moderately impaired cognition, had a lunch meal served without any fluids, despite the menu specifying an 8 oz and a 6 oz beverage at lunch and the resident’s ticket allowing one 8 oz beverage due to a 1200 ml/day fluid restriction. The following day, this resident again received a lunch meal with no fluids served. Another resident with tracheostomy, diabetes, PVD, and heart failure, and intact cognition, was served lunch meals on two consecutive days without any fluids, even though the menu called for an 8 oz and a 6 oz beverage and the meal ticket specified 2% milk (8 oz) and hot coffee or tea (6 oz). The Dietary Manager explained that beverages had been removed from trays due to spilling and were being sent separately, and that he was unaware residents were not consistently receiving beverages as planned. Across these cases, surveyors observed that residents did not receive beverages as listed on the menu or meal tickets, or as ordered, during lunch meals. Staff interviews confirmed that meal tickets should have been followed and that beverages were expected to be provided with meals. The Dietary Manager acknowledged that drinks were being sent separately from trays due to spill concerns and that there was an error in the menu software offering milk at lunch, while also stating that no concerns had been raised to him about residents not receiving beverages according to the menu, preferences, and physician orders.
Failure to Post Enhanced Barrier Precaution Signage for Resident With Tracheostomy
Penalty
Summary
Facility staff failed to implement the ordered enhanced barrier precautions (EHB) for a resident with a tracheostomy. The resident, admitted with diagnoses including tracheostomy status and a feeding tube, had a physician’s order for "Enhanced Precaution r/t Trach every shift" active since 11/04/25. The discharge MDS documented short-term memory loss and moderately impaired cognitive abilities for daily decision-making. During surveyor rounds from 1/12/26 through 1/14/26, no EHB signage was observed on the door or wall of the resident’s room, despite the active order and the presence of a tracheostomy and enteral feeding at the bedside. Staff interviews confirmed that EHB precautions were required for residents with tracheostomies, feeding tubes, PICC lines, or dialysis, and that staff had been in-serviced on following posted EHB signs for high-contact care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, device care, and wound care. A CNA described the need to follow EHB signage for such residents, and an RN acknowledged that the resident with a tracheostomy should have been on EHB precautions and that signage should have been posted, explaining that the resident had been moved to another room the previous day and no new signage was put up. Throughout the survey, EHB signs were observed on all floors for other residents, but not for this resident, and facility leadership did not provide additional information to refute the absence of signage.
Failure to Maintain Sanitary and Comfortable Environment on 200 and 400 Units
Penalty
Summary
Facility staff failed to maintain a sanitary, clean, and comfortable environment on the 200-unit. During a tour of the unit, surveyors observed the lower numeral corridor littered with debris, with many dark spots on the floor that appeared to be uncleaned spills, and cluttered with various medical equipment. In one room, the floor was described as simply dirty, the trash can had no liner, and a used glove was on the floor. The A bed resident’s fall mats at the bedside had holes and a dark substance on them, and the floor space under the head of the bed was filled with broken, useless items, a wheelchair leg rest, and a large amount of dust and dirt; the room overall was very cluttered. The resident in the B bed reported that the A bed resident’s television remote control changed the television channels on his side of the room. In another room, the room was dark and smelly, the floor was covered with dirt and debris, and the bathroom toilet was dirty and smelly; the corridor outside this room was extremely odorous, and the odor did not dissipate over time. An EVS staff member stated she worked hard to keep the unit clean, but reported that she does not move items on the floor when mopping, instead mopping around them, and that some fall mats could not be fully cleaned despite scrubbing; she stated she documented these issues in daily notes and gave them to her supervisor. On the 400 floor, staff also failed to provide a consistently sanitary and comfortable environment. During an initial tour, a strong urine odor was detected in the hallways, and the floors had visible dirt and debris, while a housekeeper was observed standing near her cart. On a subsequent tour, the floors appeared clean and no odor was present, and several housekeeping staff were observed cleaning rooms and mopping floors. However, on a later tour, a strong urine odor was again present on the 400 floor, and only a few housekeepers were observed on the unit. In a final interview with the Administrator, DON, Regional President, and Regional Nurse Consultant, facility leadership acknowledged agreement that there were environmental concerns.
Failure to Provide RN Coverage and Competent Tracheostomy Care
Penalty
Summary
Facility staff failed to provide competent professional nursing oversight, assessment, and administration of tracheostomy care for three residents on a specialized tracheostomy unit. The facility did not ensure that a Registered Nurse (RN) was present on every shift as required, resulting in lapses in care and medication administration. For one resident, there were multiple missed doses of IV and oral vancomycin following a hospital discharge for sepsis and pneumonia, with documentation showing that antibiotics were not administered as ordered for several days. The resident exhibited worsening symptoms, including fever and low blood pressure, without adequate assessment or intervention, and was ultimately sent to the hospital in critical condition and expired the same day. Staff interviews revealed that LPNs and CNAs often felt unprepared to care for tracheostomy residents and were unsure how to recognize signs of distress or perform safe suctioning. Another resident, who was at high risk for hemorrhage due to anticoagulation therapy, experienced a critical event when an LPN, without RN supervision, performed suctioning after the resident began coughing up blood and lung tissue. The resident's oxygen saturation dropped to a dangerously low level, and the resident was sent to the hospital with a tracheal tear and subsequently expired. The care plan for this resident lacked essential interventions for tracheostomy care, such as oxygen humidification, cannula management, and suction device settings. Staff interviews confirmed that RNs were not always present on the unit, and staff felt inadequately trained to manage tracheostomy care. A third resident, who was non-verbal and dependent on staff for all care, was found deceased on the unit during a shift when no RN was present. The scheduled RN, who was new and inexperienced with tracheostomies, left the facility after realizing she would be the only RN on the unit, and the DON refused to come in to provide coverage. Facility records confirmed that only LPNs were present on the unit at the time, and an RN from another floor had to be called to pronounce the resident's death. The facility's own assessment indicated awareness of the requirement for RN coverage on the tracheostomy unit, but this was not consistently implemented.
Removal Plan
- A Registered Nurse with documented tracheostomy competency training will be assigned to the tracheostomy unit every shift 7 days per week.
- Director of Nursing (DON) or designee will verify and document on assignment sheet the presence of an RN with documented tracheostomy training.
- The Regional Director of Specialty Care or designee will ensure all RN staff scheduled to work on the tracheostomy unit have completed reeducation and competency validation in care of tracheostomy patients, prior to assuming an assignment.
- A roster of RN's will be maintained by the DON or designee and provided to staffing scheduler to ensure immediate coverage in the event of call-off.
Failure to Provide Beverages Listed on Meal Tickets
Penalty
Summary
The facility staff failed to ensure that residents received beverages listed on the menu and on their personalized meal tickets. During lunch observations, residents were served meals without the beverages that were documented as part of their meal service, and staff interviews confirmed that the drinks were not provided as expected. Resident #124 had diagnoses including dysphagia, mechanically altered PO intake, and cerebral palsy. The resident’s significant change MDS assessment coded the resident as cognitively intact for daily decision making and able to use suitable utensils to bring food and/or liquid to the mouth and swallow once the meal was placed before him. At lunch, the resident’s meal ticket listed hot coffee or hot tea, but no beverage was brought with the meal. The resident stated that he did not get anything to drink and held up his water bottle, saying he could drink that. The DON stated that the meal ticket should be followed, and the DM said beverages should have been available. Resident #122 had a diagnosis of moderate protein calorie malnutrition and a quarterly MDS that coded the resident as cognitively intact. During lunch, the resident’s meal ticket listed hot tea or coffee, but no beverage was observed on the tray other than what the resident already had on the bedside table. The resident asked LPN #2 for his tea or coffee, and the LPN was observed shrugging her shoulders and leaving the room without returning with a beverage. The DON stated that the meal ticket should be followed, and the DM stated the resident should have received the beverage. Resident #108 had diagnoses including stroke, renal failure, and heart failure, and the annual MDS coded the resident as moderately impaired for daily decision making. The resident’s lunch meal ticket allowed one 8-ounce beverage, and the menu stated residents were to receive an 8-ounce and a 6-ounce beverage at lunch, but no fluids were served during the observed meal. Resident #107 had diagnoses including tracheostomy, diabetes, PVD, and heart failure, and the admission MDS coded the resident as cognitively intact. The resident’s meal ticket listed 2 percent milk, 8 ounces, and hot coffee or hot tea, 6 ounces, but no fluids were served during either lunch observation. The ADON stated both residents should have received their beverages based on their meal tickets, and the DM stated the residents were supposed to receive meals as planned on the menu with modifications based on preferences and physician orders.
Delayed DME and HH Services After Discharge
Penalty
Summary
Facility staff failed to provide needed durable medical equipment and home health services in a timely manner for Resident #115 after discharge to home. Resident #115 had diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, morbid obesity due to excess calories, end stage renal disease, and muscle weakness. The discharge MDS coded the resident as having intact cognitive abilities for daily decision making, with a BIMS score of 15 out of 15. The resident stated that a bedside commode and front-wheeled walker ordered for home delivery were not delivered until several days after discharge, and that home health nursing and physical therapy did not begin until about a week after arriving home. The resident reported having to use a bedpan for 4 days because the bedside commode was not available, and stated that the delay in home health and physical therapy left her weaker and caused one of her legs to become flaccid. The Director of Social Services confirmed that the DME did not arrive until 12/30/25 and that home health did not begin until 1/3/26, stating this was not typical. The Director of Rehabilitation stated she provided a bedpan for discharge because the bedside commode would not be at the home before the resident arrived, and later went to the resident's home to set up the commode because the DME provider could not do so. The Administrator stated the delivery and service start times were not acceptable.
Meals Served Did Not Match Menu and Meal Tickets
Penalty
Summary
The facility failed to ensure that meals were served in accordance with the menu and meal tickets for 3 of 28 residents reviewed. The report states that the menu was to be prepared in advance, followed, updated, and reviewed by a dietician, but the meals observed did not match the documented meal tickets for Residents #124, #108, and #107. The deficiencies were identified through resident observations, staff interviews, and clinical record review. Resident #124 had diagnoses including dysphagia, mechanically altered PO intake, and cerebral palsy, and the significant change MDS indicated intact cognitive abilities. During lunch observation, the resident’s tray included roasted pork loin, gravy, diced Harvard beets, mashed potatoes, a biscuit, and apple crisp, but the meal ticket listed cornbread instead of a biscuit. The resident stated he wanted his food to help him gain weight and said he did not receive extra portions. The DON stated the meal ticket should be followed because of the resident’s weight loss and that the resident gets double portions, while the DM later stated cornbread was unavailable and a biscuit was served instead. Resident #108 had diagnoses including stroke, renal failure, and heart failure, and the MDS showed moderate cognitive impairment. During lunch observation, the resident was served roasted pork with gravy, beets, mashed potatoes, a biscuit, and an apple dessert, while the menu and personal meal ticket specified cornbread instead of a biscuit. The meal ticket also listed a regular diet with a 1200 mL fluid restriction and specific portions. The DM stated cornbread was not available because the food delivery did not occur as scheduled, and the substitute item was not updated on the menu or meal tickets because of difficulties with the menu/meal ticket software. Resident #107 had diagnoses including tracheostomy, diabetes, PVD, and heart failure, and the MDS indicated intact cognitive abilities. During lunch observation, the resident was served a whole slice of roasted pork with gravy rather than chopped pork loin as listed on the mechanically advanced/chopped diabetic meal ticket, and a biscuit was served instead of the dinner roll listed on the ticket. The DM stated the pork was not chopped in error and that dinner rolls were unavailable because the food delivery did not occur when expected; the substitute was not updated on the menu or meal tickets due to software difficulties.
Missing EHB Signage for Resident With Trach and Feeding Tube
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to ensure enhanced barrier precaution signage was posted for Resident #117. The resident was originally admitted to the facility on 10/23/25 and later readmitted after an acute care hospital stay. The resident’s diagnoses included tracheostomy status, and the discharge MDS with ARD 12/17/25 coded short-term memory loss with moderately impaired cognitive abilities for daily decision making, as well as a feeding tube in Section K. A physician order summary for December 2025 included Enhanced Precaution related to trach every shift, active from 11/04/25. During the initial tour on 1/13/26 and again on 1/14/26, surveyors observed no enhanced barrier precaution sign on the resident’s door or wall before entering room [ROOM NUMBER] B. The resident was observed resting in bed with eyes closed, with a tracheostomy attached and enteral feeding at the bedside. Staff interviews on 1/14/26 indicated CNA #3 understood that residents with tracheostomies and feeding tubes required EHB precautions and that staff must follow the signage for gown, mask, and glove use during care. RN #1 stated that residents with a PICC line, trach, or dialysis should be on EHB precautions and acknowledged that Resident #117 should have had EHB signage posted, adding that because the resident had been moved to another room the day before, no signage was put up.
Sanitary and Comfortable Environment Not Maintained
Penalty
Summary
The facility staff failed to maintain a sanitary and comfortable environment in the 200-unit. During observation, it took 12 minutes from the time the call button was activated until the elevator arrived at the front lobby. On the lower numeral corridor, debris was observed on the floor, along with many dark spots that appeared to be uncleaned spills, and the corridor was cluttered with various medical equipment. In one room, the floor was dirty, the trash can had no liner, and a used glove was on the floor. The A bed resident had bedside mats with holes and a dark substance on them, and the area under the head of the bed contained broken, useless items, a wheelchair leg rest, and a large amount of dust and dirt. The room was very cluttered, and the B bed resident stated that the A bed resident had a television remote control that changed the television channels on his side of the room. In another room, the room was dark and smelly, the floor was covered with dirt and debris, and the bathroom toilet was dirty and smelly. The corridor was also extremely odorous after passing that room, and the odor did not dissipate over time. The EVS staff stated that she mopped around items on the floor because she did not know what they were, and that she had scrubbed the fall mats but was unsuccessful in getting some of them clean. On the 400 floor, a strong urine odor was detected in the hallways and the floors had dirt and debris during one tour, while a later tour found the floors clean and no odor present with several housekeeping staff cleaning rooms and mopping floors. On another tour, a strong urine odor was again present and only a few housekeepers were noticed on the unit. The Administrator, DON, Regional President, and Regional Nurse Consultant later acknowledged that there were environmental concerns.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility's staff failed to provide timely incontinence care for a resident who was always incontinent of bladder and frequently incontinent of bowels. The resident, who had intact cognitive abilities and was at risk for pressure ulcers, reported waiting for hours to be cleaned up, which prevented participation in activities. The care plan for the resident included keeping the skin clean and dry, applying a moisture barrier, and cleaning the peri area with each incontinent episode. However, the staff did not adhere to these interventions, as evidenced by the resident's report and the observation of a heavily saturated brief. During an interview, a CNA acknowledged that the resident had been waiting a while to be changed and stated she would attend to the resident after assisting another. An LPN observed the resident's brief was heavily saturated but considered the resident okay since the urine was contained within the brief. These actions and inactions led to the deficiency, as the facility staff did not provide timely incontinence care, which was confirmed through resident and staff interviews, clinical record reviews, and observations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Norfolk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harbor's Edge | 1 mi | ★★★★★ | 2 | 0 |
| Signature Healthcare Of Norfolk | 1.6 mi | ★★★★★ | 0 | 0 |
| Ghent Health And Rehabilitation | 1.8 mi | ★★★★★ | 34 | 0 |
| Portsmouth Health And Rehab | 2.3 mi | ★★★★★ | 7 | 1 |
| Norview Heights Rehabilitation And Nursing | 2.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.