Deficiency Records for Norfolk Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Norfolk Health 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-16 | 2023-03-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-16 | 2023-03-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-07 | 2022-05-06 | 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 | 2022-04-07 | 2022-05-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-07 | 2022-05-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-07 | 2022-05-06 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-04-07 | 2022-05-06 | Y |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-07-15 | 2021-08-18 | 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 | 2021-07-15 | 2021-08-18 | 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 | 2021-07-15 | 2021-08-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-15 | 2021-08-18 | 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 | 2021-07-15 | 2021-08-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-15 | 2021-08-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-15 | 2021-08-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-15 | 2021-08-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-15 | 2021-08-18 | N |
| 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 | 2021-07-15 | 2021-08-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-15 | 2021-08-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-07-15 | 2021-08-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-15 | 2021-08-18 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-07-15 | 2021-08-18 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-07-15 | 2021-08-18 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-07-15 | 2021-08-18 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-07-15 | 2021-08-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-07-15 | 2021-08-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-21 | 2021-08-05 | N |
| Meet other general requirements. | Fire Safety | 2021-07-21 | 2021-08-05 | N |
| 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 | 2020-01-14 | 2020-03-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-14 | 2020-03-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-14 | 2020-03-11 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2020-01-14 | 2020-03-11 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-01-14 | 2020-03-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-14 | 2020-03-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-14 | 2020-03-11 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-05-09 | 2019-06-17 | 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 | 2019-05-09 | 2019-06-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-09 | 2019-06-17 | 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 | 2019-05-09 | 2019-06-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-09 | 2019-06-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-09 | 2019-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-09 | 2019-06-17 | 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 | 2019-05-09 | 2019-06-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-09 | 2019-06-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-09 | 2019-06-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-09 | 2019-06-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-09 | 2019-06-17 | 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 | 2019-05-09 | 2019-06-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-09 | 2019-06-17 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-05-09 | 2019-06-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-09 | 2019-06-17 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-05-09 | 2019-06-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-09 | 2019-06-17 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-05-09 | 2019-06-17 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-09 | 2019-06-17 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-05-09 | 2019-06-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-05-09 | 2019-06-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-09 | 2019-06-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-09-01 | 2017-10-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-09-01 | 2017-10-11 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-08-17 | 2017-09-27 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-17 | 2017-09-27 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-08-17 | 2017-09-27 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-08-17 | 2017-09-27 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-17 | 2017-09-27 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2017-08-17 | 2017-09-27 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-08-17 | 2017-09-27 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-17 | 2017-09-27 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-08-17 | 2017-09-27 | N |
