A list of the most recent deficiencies for Signature Healthcare of Norfolk. 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? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-07-21 | 2023-08-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-21 | 2023-08-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-21 | 2023-08-31 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-07-21 | 2023-08-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-21 | 2023-08-31 | 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 | 2023-07-21 | 2023-08-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-21 | 2023-08-31 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-07-21 | 2023-08-31 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-21 | 2023-08-31 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-25 | 2023-08-23 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-07-25 | 2023-08-23 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-07-25 | 2023-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-25 | 2023-08-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-26 | 2021-09-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-24 | 2020-01-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-24 | 2020-01-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-24 | 2020-01-05 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-10-24 | 2019-12-08 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-10-24 | 2019-12-08 | N |
| 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 | 2019-10-24 | 2019-12-08 | 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 | 2019-10-24 | 2019-12-08 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-10-24 | 2019-12-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-24 | 2019-12-08 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-10-24 | 2019-12-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-24 | 2019-12-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-24 | 2019-12-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-24 | 2019-12-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-10-24 | 2019-12-08 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-10-24 | 2019-12-08 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-10-24 | 2019-12-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-24 | 2019-12-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-24 | 2019-12-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-24 | 2019-12-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-24 | 2019-12-08 | N |
| Post nurse staffing information every day. | Health | 2019-10-24 | 2019-12-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-24 | 2019-12-08 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-10-24 | 2019-12-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-24 | 2019-12-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-24 | 2019-12-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-10-24 | 2019-12-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-10-24 | 2019-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-24 | 2019-12-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-24 | 2019-12-08 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-10-24 | 2019-12-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-24 | 2019-11-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-03 | 2018-09-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-08-03 | 2018-09-19 | 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 | 2018-07-13 | 2018-08-31 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-07-13 | 2018-08-08 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-07-13 | 2018-08-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-07-13 | 2018-08-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-07-13 | 2018-08-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-07-13 | 2018-08-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-13 | 2018-08-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-07-13 | 2018-08-08 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-07-13 | 2018-08-08 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-07-13 | 2018-08-08 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-07-13 | 2018-08-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-07-13 | 2018-08-08 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-07-13 | 2018-08-08 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-07-13 | 2018-08-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-07-13 | 2018-08-08 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-07-13 | 2018-08-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-07-13 | 2018-08-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-07-13 | 2018-08-08 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-07-13 | 2018-08-08 | N |
