SIGNATURE HEALTHCARE OF NORFOLK Inspection Report, Violations & Safety Grade (NORFOLK, Virginia)

1005 HAMPTON BLVD, NORFOLK, Virginia 23507

Phone: 7576235602

CMS Overall:3/5

Overview & Bed Count

Certified Beds

169

Avg Residents/Day

154.4

Ownership

For profit - Corporation

Provider Type

Medicare and Medicaid

County

Norfolk City

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall3/5

Health2/5

Staffing3/5

Quality5/5

Nurse Staffing Check

Metric	This Facility	Virginia Avg	Difference
RN Hours per Resident per Day	0.47	0.71	-0.24
Total Nurse Hours per Resident per Day	3.54	3.88	-0.33
CMS Staffing Rating	3/5	2.5/5	-
Nursing Staff Turnover	46.8%	47.5%	-

Health Citation History

47 health citations on record

Date	Category	Description	Severity
2023-07-21	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
2023-07-21	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	E – Moderate Harm Potential
2023-07-21	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	E – Moderate Harm Potential
2023-07-21	Pharmacy Service Deficiencies	Ensure that residents are free from significant medication errors.	E – Moderate Harm Potential
2023-07-21	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
2023-07-21	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.	D – Moderate Harm Potential
2023-07-21	Resident Assessment and Care Planning Deficiencies	Plan the resident's discharge to meet the resident's goals and needs.	D – Moderate Harm Potential
2023-07-21	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
2023-07-21	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
2019-10-24	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	G – Actual Harm
2019-10-24	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2019-10-24	Environmental Deficiencies	Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.	F – Moderate Harm Potential
2019-10-24	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2019-10-24	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2019-10-24	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2019-10-24	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	E – Moderate Harm Potential
2019-10-24	Quality of Life and Care Deficiencies	Provide safe, appropriate dialysis care/services for a resident who requires such services.	E – Moderate Harm Potential
2019-10-24	Administration Deficiencies	Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.	E – Moderate Harm Potential
2019-10-24	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
2019-10-24	Administration Deficiencies	Have the Quality Assessment and Assurance group have the required members and meet at least quarterly	E – Moderate Harm Potential
2019-10-24	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
2019-10-24	Resident Rights Deficiencies	Honor the resident's right to manage his or her financial affairs.	D – Moderate Harm Potential
2019-10-24	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.	D – Moderate Harm Potential
2019-10-24	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
2019-10-24	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	D – Moderate Harm Potential
2019-10-24	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
2019-10-24	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2019-10-24	Resident Assessment and Care Planning Deficiencies	Plan the resident's discharge to meet the resident's goals and needs.	D – Moderate Harm Potential
2019-10-24	Resident Assessment and Care Planning Deficiencies	Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.	D – Moderate Harm Potential
2019-10-24	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2019-10-24	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	D – Moderate Harm Potential
2019-10-24	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2019-10-24	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	D – Moderate Harm Potential
2019-10-24	Pharmacy Service Deficiencies	Ensure that residents are free from significant medication errors.	D – Moderate Harm Potential
2019-10-24	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	D – Moderate Harm Potential
2019-10-24	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2019-10-24	Nursing and Physician Services Deficiencies	Post nurse staffing information every day.	C – Minimal Harm Potential
2019-10-24	Resident Rights Deficiencies	Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.	B – Minimal Harm Potential
2019-10-24	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	B – Minimal Harm Potential
2019-10-24	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	B – Minimal Harm Potential
2018-07-13	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	G – Actual Harm
2018-07-13	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	G – Actual Harm
2018-07-13	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2018-07-13	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
2018-07-13	Resident Rights Deficiencies	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	D – Moderate Harm Potential
2018-07-13	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2018-07-13	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential

Fire Safety Citation History

18 fire safety citations on record

Date	Category	Description	Severity
2023-07-21	Smoke Deficiencies	Provide properly protected cooking facilities.	E – Moderate Harm Potential
2023-07-21	Smoke Deficiencies	Properly provide smoke detection systems in areas open to corridors.	E – Moderate Harm Potential
2023-07-21	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential
2023-07-21	Smoke Deficiencies	Have properly installed hallway dispensers for alcohol-based hand rub.	D – Moderate Harm Potential
2018-07-13	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	D – Moderate Harm Potential
2018-07-13	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper medical gas storage and administration areas.	D – Moderate Harm Potential
2018-07-13	Emergency Preparedness Deficiencies	Develop and maintain an Emergency Preparedness Program (EP).	C – Minimal Harm Potential
2018-07-13	Emergency Preparedness Deficiencies	Conduct risk assessment and an All-Hazards approach.	C – Minimal Harm Potential
2018-07-13	Emergency Preparedness Deficiencies	Address patient/client population and determine types of services needed.	C – Minimal Harm Potential
2018-07-13	Emergency Preparedness Deficiencies	Develop Emergency Preparedness policies and procedures.	C – Minimal Harm Potential
2018-07-13	Emergency Preparedness Deficiencies	Address subsistence needs for staff and patients.	C – Minimal Harm Potential
2018-07-13	Emergency Preparedness Deficiencies	Establish procedures for tracking staff and patients during an emergency.	C – Minimal Harm Potential
2018-07-13	Emergency Preparedness Deficiencies	Establish policies and procedures for sheltering.	C – Minimal Harm Potential
2018-07-13	Emergency Preparedness Deficiencies	Establish roles under a Waiver declared by secretary.	C – Minimal Harm Potential
2018-07-13	Emergency Preparedness Deficiencies	Provide family notifications of emergency plan.	C – Minimal Harm Potential
2018-07-13	Emergency Preparedness Deficiencies	Establish emergency prep training and testing.	C – Minimal Harm Potential
2018-07-13	Emergency Preparedness Deficiencies	Establish staff and initial training requirements.	C – Minimal Harm Potential
2018-07-13	Emergency Preparedness Deficiencies	Implement emergency and standby power systems.	C – Minimal Harm Potential

Total Penalties & Fines

Total Fine Amount (CMS)

Number of Fines

Total Penalties

No penalty records found.

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3-Year Complete Report ($19)

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