A list of the most recent deficiencies for Consulate Health Care 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 a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-10-24 | 2023-01-21 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-10-24 | 2023-01-21 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-10-24 | 2023-01-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-24 | 2023-01-21 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-10-24 | 2023-01-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-24 | 2022-12-06 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-10-24 | 2022-12-06 | Y |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2022-10-24 | 2022-12-06 | 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 | 2022-01-18 | 2022-03-01 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2022-01-18 | 2022-03-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-11-11 | 2021-12-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-11 | 2021-12-26 | 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 | 2021-11-11 | 2021-12-26 | N |
| Respond appropriately to all alleged violations. | Health | 2021-11-11 | 2021-12-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-11-11 | 2021-12-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-11 | 2021-12-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-11 | 2021-12-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-11 | 2021-12-26 | 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 | 2021-11-11 | 2021-12-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-11 | 2021-12-26 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-11-11 | 2021-12-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-11-11 | 2021-12-26 | N |
| Post nurse staffing information every day. | Health | 2021-11-11 | 2021-12-26 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-11 | 2021-12-26 | 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 | 2021-11-11 | 2021-12-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-11 | 2021-12-26 | N |
| Keep all essential equipment working safely. | Health | 2021-11-11 | 2021-12-26 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-11-11 | 2021-12-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-11 | 2021-12-26 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-11-11 | 2021-12-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-11 | 2021-12-26 | 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 | 2019-02-19 | 2019-05-13 | 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 | 2019-02-19 | 2019-05-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-19 | 2019-05-13 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-02-19 | 2019-04-06 | 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 | 2019-02-19 | 2019-04-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-19 | 2019-04-06 | 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 | 2019-02-19 | 2019-04-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-19 | 2019-04-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-19 | 2019-04-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-19 | 2019-04-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-19 | 2019-04-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-19 | 2019-04-06 | N |
| Provide or obtain dental services for each resident. | Health | 2019-02-19 | 2019-04-06 | 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 | 2019-02-19 | 2019-04-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-02-19 | 2019-04-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-02-19 | 2019-04-06 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-02-19 | 2019-04-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-06-23 | 2017-10-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-06-23 | 2017-08-31 | 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 | 2017-06-23 | 2017-08-31 | 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 | 2017-06-23 | 2017-08-31 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2017-06-23 | 2017-08-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-06-23 | 2017-08-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-06-23 | 2017-08-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-06-23 | 2017-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-23 | 2017-08-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-06-23 | 2017-08-31 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2017-06-23 | 2017-08-31 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2017-06-23 | 2017-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-06-23 | 2017-08-31 | N |
| Honor a residents' rights as a residents of the nursing home, free of coercion and reprisal, and as citizens or residents of the United States. | Health | 2017-06-08 | 2017-07-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-06-08 | 2017-07-14 | N |
| Provide housekeeping and maintenance services. | Health | 2017-06-08 | 2017-07-14 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-06-08 | 2017-07-14 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-06-08 | 2017-07-14 | N |
| Dispose of garbage and refuse properly. | Health | 2017-06-08 | 2017-07-14 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-06-08 | 2017-07-14 | N |
