Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Norfolk Health Care Center

NORFOLK, VA · 180 certified beds · Last Life Safety survey July 15, 2021

CMS Certification Number 495210 · first certified May 1990

Ownership

Operated by LIFEWORKS REHAB · For profit - Corporation

  • Ownership changed May 28, 2021 (change of ownership)to NORFOLK HEALTH & REHABILITATION CENTER from MEDICAL FACILITIES OF AMERICA XLI
23
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
3
Tags cited more than once
Across separate surveys
7
Inspection & testing records
Of the citations on file

Position within VA

23 citations — more than 88% of the 289 certified nursing homes in VA. Compared within VA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 7 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (February 2024 to February 2025), and past the point by which nine in ten VA facilities have been surveyed. This facility’s last Life Safety survey was July 2021. Facilities in VA are typically surveyed 31–43 months after the last one (median 37), measured over 125 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

12 of the 23 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  • F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.

This facility23VA median10National median11
Citations on file over three years, compared
MeasureCitations
This facility23
Median facility in VA10
Median facility nationally11

Survey history

Citations at each Life Safety survey
22017-08142019-0572021-07
Citations at each Life Safety survey
Survey dateCitations
August 17, 20172
May 9, 201914
July 15, 20217

Most-cited tags

Most-cited tags at this facility
E-00072K-03722E-00372E-00131K-05311K-09181E-00241K-03531
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
E-0007Address patient/client population and determine types of services needed.22021-07-15
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.22019-05-09
E-0037Establish staff and initial training requirements.22021-07-15
E-0013Develop Emergency Preparedness policies and procedures.12021-07-15
K-0531Have elevators that firefighters can control in the event of a fire.12019-05-09
K-0918Have generator or other power source capable of supplying service within 10 seconds.12019-05-09
E-0024Establish policies and procedures for volunteers.12019-05-09
K-0353Inspect, test, and maintain automatic sprinkler systems.12019-05-09

What the citations cover

Citations by CMS category
  • Emergency Preparedness Deficiencies 12
  • Smoke Deficiencies 5
  • Miscellaneous Deficiencies 3
  • Egress Deficiencies 1
  • Other 2
Citations by CMS category
CategoryCitations
Emergency Preparedness Deficiencies12
Smoke Deficiencies5
Miscellaneous Deficiencies3
Egress Deficiencies1
Services Deficiencies1
Gas, Vacuum, and Electrical Systems Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

July 15, 2021 — 7 citations

Citations issued on July 15, 2021
TagWhat the surveyor checksStatus
E-0006Conduct risk assessment and an All-Hazards approach.Deficient, Provider has date of correction (August 18, 2021)
E-0007Address patient/client population and determine types of services needed.Deficient, Provider has date of correction (August 18, 2021)
E-0013Develop Emergency Preparedness policies and procedures.Deficient, Provider has date of correction (August 18, 2021)
E-0030List the names and contact information of those in the facility.Deficient, Provider has date of correction (August 18, 2021)
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (August 18, 2021)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (August 5, 2021)
K-0932Meet other general requirements.Deficient, Provider has date of correction (August 5, 2021)

May 9, 2019 — 14 citations

Citations issued on May 9, 2019
TagWhat the surveyor checksStatus
E-0007Address patient/client population and determine types of services needed.Deficient, Provider has date of correction (June 17, 2019)
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (June 17, 2019)
E-0024Establish policies and procedures for volunteers.Deficient, Provider has date of correction (June 17, 2019)
E-0026Establish roles under a Waiver declared by secretary.Deficient, Provider has date of correction (June 17, 2019)
E-0034Provide a means of sharing information on occupancy/needs.Deficient, Provider has date of correction (June 17, 2019)
E-0036Establish emergency prep training and testing.Deficient, Provider has date of correction (June 17, 2019)
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (June 17, 2019)
K-0222Add 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.Deficient, Provider has date of correction (March 11, 2020)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (March 11, 2020)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (March 11, 2020)
K-0531Have elevators that firefighters can control in the event of a fire.Deficient, Provider has date of correction (March 11, 2020)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (March 11, 2020)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (March 11, 2020)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (March 11, 2020)

August 17, 2017 — 2 citations

Citations issued on August 17, 2017
TagWhat the surveyor checksStatus
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (October 11, 2017)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (October 11, 2017)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.