Ghent Health and Rehabilitation Inspection Report, Violations & Safety Grade (NORFOLK, Virginia)

3900 LLEWELLYN AVE, NORFOLK, Virginia 23504

Phone: 7576255363

CMS Overall:1/5

Overview & Bed Count

Certified Beds

222

Avg Residents/Day

158.4

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Norfolk City

Sprinkler Systems

Yes

Special Focus

None

Abuse Citation

Yes

CMS Star Ratings

Overall1/5

Health1/5

Staffing3/5

Quality3/5

Nurse Staffing Check

Metric	This Facility	Virginia Avg	Difference
RN Hours per Resident per Day	0.36	0.71	-0.35
Total Nurse Hours per Resident per Day	3.01	3.88	-0.86
CMS Staffing Rating	3/5	2.5/5	-
Nursing Staff Turnover	53.2%	47.5%	-

Health Citation History

69 health citations on record

Date	Category	Description	Severity
2026-02-26	Resident Rights Deficiencies	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.	F – Moderate Harm Potential
2026-02-26	Infection Control Deficiencies	Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.	F – Moderate Harm Potential
2026-02-26	Resident Rights Deficiencies	Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.	E – Moderate Harm Potential
2026-02-26	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2026-02-26	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	E – Moderate Harm Potential
2026-02-26	Quality of Life and Care Deficiencies	Provide safe, appropriate dialysis care/services for a resident who requires such services.	E – Moderate Harm Potential
2026-02-26	Administration Deficiencies	Administer the facility in a manner that enables it to use its resources effectively and efficiently.	E – Moderate Harm Potential
2026-02-26	Administration Deficiencies	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.	E – Moderate Harm Potential
2026-02-26	Administration Deficiencies	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	E – Moderate Harm Potential
2026-02-26	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2026-02-26	Environmental Deficiencies	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	E – Moderate Harm Potential
2026-02-26	Environmental Deficiencies	Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.	E – Moderate Harm Potential
2026-02-26	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2026-02-26	Resident Rights Deficiencies	Ensure residents have reasonable access to and privacy in their use of communication methods.	D – Moderate Harm Potential
2026-02-26	Resident Rights Deficiencies	Keep residents' personal and medical records private and confidential.	D – Moderate Harm Potential
2026-02-26	Resident Rights Deficiencies	Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	D – Moderate Harm Potential
2026-02-26	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	D – Moderate Harm Potential
2026-02-26	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2026-02-26	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2026-02-26	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2026-02-26	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	D – Moderate Harm Potential
2026-02-26	Quality of Life and Care Deficiencies	Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.	D – Moderate Harm Potential
2026-02-26	Quality of Life and Care Deficiencies	Provide safe, appropriate pain management for a resident who requires such services.	D – Moderate Harm Potential
2026-02-26	Quality of Life and Care Deficiencies	Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.	D – Moderate Harm Potential
2026-02-26	Nutrition and Dietary Deficiencies	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.	D – Moderate Harm Potential
2026-02-26	Nutrition and Dietary Deficiencies	Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.	D – Moderate Harm Potential
2026-02-26	Administration Deficiencies	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.	D – Moderate Harm Potential
2026-02-26	Environmental Deficiencies	Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.	D – Moderate Harm Potential
2024-07-19	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2024-07-19	Environmental Deficiencies	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	E – Moderate Harm Potential
2024-07-19	Quality of Life and Care Deficiencies	Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.	D – Moderate Harm Potential
2021-11-11	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	G – Actual Harm
2021-11-11	Environmental Deficiencies	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	F – Moderate Harm Potential
2021-11-11	Environmental Deficiencies	Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.	F – Moderate Harm Potential
2021-11-11	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2021-11-11	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	E – Moderate Harm Potential
2021-11-11	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	E – Moderate Harm Potential
2021-11-11	Quality of Life and Care Deficiencies	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.	E – Moderate Harm Potential
2021-11-11	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	E – Moderate Harm Potential
2021-11-11	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2021-11-11	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2021-11-11	Environmental Deficiencies	Keep all essential equipment working safely.	E – Moderate Harm Potential
2021-11-11	Resident Rights Deficiencies	Allow residents to self-administer drugs if determined clinically appropriate.	D – Moderate Harm Potential
2021-11-11	Resident Rights Deficiencies	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	D – Moderate Harm Potential
2021-11-11	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	D – Moderate Harm Potential
2021-11-11	Resident Assessment and Care Planning Deficiencies	PASARR screening for Mental disorders or Intellectual Disabilities	D – Moderate Harm Potential
2021-11-11	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2021-11-11	Nursing and Physician Services Deficiencies	Ensure that the resident and his/her doctor meet face-to-face at all required visits.	D – Moderate Harm Potential
2021-11-11	Nursing and Physician Services Deficiencies	Observe each nurse aide's job performance and give regular training.	D – Moderate Harm Potential
2021-11-11	Pharmacy Service Deficiencies	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	D – Moderate Harm Potential

Showing 50 of 69 citations.

Fire Safety Citation History

8 fire safety citations on record

Date	Category	Description	Severity
2026-02-26	Emergency Preparedness Deficiencies	Address subsistence needs for staff and patients.	E – Moderate Harm Potential
2026-02-26	Emergency Preparedness Deficiencies	Conduct testing and exercise requirements.	E – Moderate Harm Potential
2026-02-26	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	D – Moderate Harm Potential
2026-02-26	Smoke Deficiencies	Provide properly protected cooking facilities.	D – Moderate Harm Potential
2026-02-26	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	D – Moderate Harm Potential
2026-02-26	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure that testing and maintenance of electrical equipment is performed.	D – Moderate Harm Potential
2021-11-11	Egress Deficiencies	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.	E – Moderate Harm Potential
2021-11-11	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper power supply for life support equipment.	D – Moderate Harm Potential

Total Penalties & Fines

Total Fine Amount (CMS)

Number of Fines

Total Penalties

No penalty records found.

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Verified Helpline

Care & Coverage Review

Researching facilities in NORFOLK, Virginia? Speak with a licensed specialist to review your Medicare or health insurance benefits at no cost.

📞 Call (866) 227-7595
Medicare & Benefits Review
(Ages 64.5+)📞 Call (866) 228-4856
Health Insurance Helpline
(Ages 26–64)

Free, confidential consultation. We may receive referral compensation.