Deficiencies (last 3 years)
Deficiencies (over 3 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% worse than Virginia average
Virginia average: 9.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 8
Jul 21, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of Signature Healthcare of Norfolk to assess compliance with federal regulations related to resident rights, care, safety, and medication management.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights to personal possessions, failure to immediately notify physicians of significant condition changes, failure to ensure safe and clean environment, failure to provide timely discharge notices, failure to involve residents or representatives in care planning, failure to plan effective discharge, failure to provide complete ADL care, failure to monitor and treat urinary tract infections timely, and failure to prevent significant medication errors.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to treat residents with respect and dignity by not ensuring residents' rights to retain personal possessions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to immediately inform physician of significant deterioration in resident's condition resulting in subdural hematoma. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure the sink in a resident's room drained properly, impacting resident comfort and safety. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide written discharge notices to residents and/or representatives at time of hospital transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to invite resident or responsible representative to participate in person-centered care plan meeting. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to assist dependent resident with activities of daily living including hair care, oral care, and nail care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate care to monitor, assess, and treat urinary tract infection in a timely manner. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure resident was free from significant medication errors related to omission of blood pressure medication. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Missed doses: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Documented swelling and bruising on Resident #46 | |
| Licensed Practical Nurse #8 | Documented increased pain in Resident #46's left eye | |
| Psych Nurse Practitioner (NP) | Ordered labs and evaluated Resident #46 for agitation and UTI | |
| Physical Therapist | Evaluated Resident #46 after falls and functional decline | |
| Assistant Director of Nursing (ADON) | Discussed labeling machine for residents' clothing | |
| Activities Director | Discussed labeling residents' clothing and yard sale | |
| Certified Nursing Assistant (CNA) #8 | Responsible for hair washing and oral care of Resident #1 | |
| Director of Nursing (DON) | Interviewed regarding failure to notify physician and medication error | |
| Social Worker #1 | Assisted Resident #114 with discharge planning |
Inspection Report
Complaint Investigation
Deficiencies: 5
Jul 21, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to immediately inform the physician of significant deterioration in Resident #46's condition, failure to ensure proper care and treatment for residents including medication administration errors, and issues related to resident safety and hygiene.
Findings
The facility failed to immediately notify the physician about Resident #46's significant condition changes, resulting in delayed treatment for subdural hematoma and urinary tract infection. Additional deficiencies included failure to ensure proper ADL care for Resident #1, unresolved maintenance issues affecting Resident #120, and a significant medication error involving Resident #236. The facility did not adequately assess or treat Resident #46's worsening condition between 05/12/23 and 05/22/23.
Complaint Details
The complaint investigation focused on Resident #46's failure to receive timely physician notification and treatment for significant condition changes including falls, neurological decline, and urinary tract infection. Additional complaints involved maintenance issues affecting Resident #120, inadequate ADL care for Resident #1, and medication errors for Resident #236.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to immediately inform the physician of significant deterioration in Resident #46's condition leading to delayed assessment and treatment of subdural hematoma. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure the sink in Resident #120's room drained properly, causing standing water for months. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure dependent Resident #1's activities of daily living were completed, including hair care, oral care, and nail care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely monitor, assess, and treat Resident #46 for signs and symptoms of urinary tract infection. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #236 received prescribed medication Lopressor 25 mg twice daily from 11/14/20 through 11/20/20, resulting in missed doses. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents in survey sample: 59
Falls: 4
BIMS score: 3
BIMS score: 15
BIMS score: 14
Missed medication doses: 13
Antibiotic dosage: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NP #1 | Psych Nurse Practitioner | Ordered labs and evaluated Resident #46 for increased agitation and UTI symptoms |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding failure to notify physician and assess Resident #46; also identified medication error for Resident #236 |
| Certified Nursing Assistant #8 | CNA | Provided information about ADL care responsibilities for Resident #1 |
| Physical Therapist | Physical Therapist (PT) | Evaluated Resident #46 after falls and noted significant decline in mobility |
Inspection Report
Complaint Investigation
Census: 156
Capacity: 169
Deficiencies: 18
Oct 24, 2019
Visit Reason
The inspection was conducted based on complaints and concerns regarding multiple areas including residents' rights to manage financial affairs, access to survey results, advance directives, discharge planning, pressure ulcer care, medication administration, infection control, and other quality of care issues.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to manage financial affairs, failure to provide three years of survey results for public review, failure to maintain and provide advance directives, failure to send care plan summaries and discharge notices upon hospital transfers, failure to provide appropriate pressure ulcer care, medication administration errors, infection control lapses, and inadequate quality assurance processes.
Complaint Details
The complaint investigation revealed multiple deficiencies including failure to ensure residents' rights, care planning, discharge planning, pressure ulcer care, medication administration, infection control, and quality assurance. Specific complaints included failure to establish patient trust fund accounts, failure to provide advance directives, failure to send care plans and discharge notices to hospitals, failure to notify the Ombudsman of discharges, and failure to prevent falls and pressure ulcers.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Level of Harm - Potential for minimal harm: 3
Level of Harm - Actual harm: 2
Deficiencies (18)
| Description | Severity |
|---|---|
| Facility staff failed to ensure Resident #20 had a patient trust fund account. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to make 3 years of survey results and corresponding plans of correction available for review. | Level of Harm - Potential for minimal harm |
| Facility staff failed to ensure residents were able to formulate, obtain, and maintain advance directives in clinical records for 16 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to send care plan summaries and discharge summaries to receiving hospitals for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for Resident #11. | Level of Harm - Potential for minimal harm |
| Facility staff failed to issue bed hold notices to residents or representatives upon hospital transfers for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to develop a baseline care plan for Resident #155 within 48 hours of admission. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to address Activities of Daily Living (ADLs) in the comprehensive care plan for Resident #403. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to review and revise person-centered care plans as residents' conditions changed for 5 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to ensure appropriate pressure ulcer care and prevention for Resident #11, resulting in a stage 3 sacral pressure ulcer. | Level of Harm - Actual harm |
| Facility staff failed to follow physician orders for oxygen flow rate for Resident #94. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to ensure dialysis services included ongoing communication with the dialysis center for Resident #18. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to post daily nursing staffing information including actual hours worked. | Level of Harm - Potential for minimal harm |
| Facility staff failed to ensure medication Procrit was available and administered as ordered for Resident #88. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to ensure timely notification of positive urine culture to physician for Resident #78. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to ensure infection control practices during wound care for Resident #32. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to maintain an effective pest control program, with presence of flies in multiple areas. | Level of Harm - Potential for minimal harm |
| Facility staff failed to ensure Resident #113 was free from an avoidable fall from bed during care, resulting in fractured ribs. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 156
Facility capacity: 169
Residents with advance directive issues: 16
Residents with care plan summary not sent: 10
Residents with bed hold notice not issued: 9
Residents with pressure ulcer care deficiencies: 1
Residents with oxygen flow rate error: 1
Residents with dialysis communication issues: 1
Residents with medication error: 1
Residents with infection control lapses: 1
Residents with avoidable falls: 1
Inspection Report
Routine
Deficiencies: 9
Jul 13, 2018
Visit Reason
The inspection was a routine survey to assess compliance with Medicare and Medicaid regulations, including review of resident care, medication management, safety, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to issue Medicare Beneficiary Notices, failure to provide bed hold and reserve bed payment policy notices, inaccurate resident assessments, incomplete care plans, pressure ulcer care deficiencies, accident hazard prevention failures, and medication storage and security issues.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Level of Harm - Actual harm: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to issue Advanced Beneficiary Notices (ABN) to residents discharged from skilled services with Medicare days remaining. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide notice of Bed Hold and Reserve Bed Payment Policy to multiple residents upon discharge to hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete accurate Minimum Data Set (MDS) assessments including coding for hospice care and mental status. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and revise comprehensive care plans reflecting resident preferences and post-fall interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to prevent and timely identify a stage 3 pressure ulcer resulting in harm to a resident. | Level of Harm - Actual harm |
| Failure to maintain environment free from accident hazards resulting in second degree burns and ingestion of paint by residents. | Level of Harm - Actual harm |
| Failure to ensure medications supplied by family were stored appropriately and not left at resident bedside. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to discard expired medications and biologicals and failure to secure medication carts and medications from residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to secure medications leading to ingestion of anti-fungal ointment by a resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents in survey sample: 38
Residents affected by ABN deficiency: 2
Residents affected by Bed Hold notice deficiency: 5
Residents affected by MDS assessment deficiency: 2
Residents affected by care plan deficiency: 2
Residents affected by pressure ulcer deficiency: 1
Residents affected by accident hazard deficiency: 2
Residents affected by medication storage deficiency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Conducted follow-up assessment of pressure ulcer for Resident #108 |
| LPN #6 | Licensed Practical Nurse | Observed pressure ulcer on Resident #108 and reported incident of paint ingestion by Resident #25 |
| LPN #8 | Licensed Practical Nurse | Regular nurse for Resident #13, acknowledged medications should not be at bedside |
| RN #2 | Registered Nurse | Unit Manager responsible for medication storage and removal of expired medications |
| Assistant Business Manager | Interviewed regarding misunderstanding of Medicare Beneficiary Notices | |
| Director of Nursing | Director of Nursing | Interviewed regarding bed hold notification and medication storage policies |
| Administrator | Administrator | Interviewed regarding hot liquid burn incident and paint ingestion incident |
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