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
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
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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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
Compared with the median facility in VA, and nationally. Surveyors differ markedly between states, so the VA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 23 |
| Median facility in VA | 10 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 17, 2017 | 2 |
| May 9, 2019 | 14 |
| July 15, 2021 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | 2 | 2021-07-15 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2019-05-09 |
| E-0037 | Establish staff and initial training requirements. | 2 | 2021-07-15 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 1 | 2021-07-15 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 1 | 2019-05-09 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2019-05-09 |
| E-0024 | Establish policies and procedures for volunteers. | 1 | 2019-05-09 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2019-05-09 |
What the citations cover
- Emergency Preparedness Deficiencies 12
- Smoke Deficiencies 5
- Miscellaneous Deficiencies 3
- Egress Deficiencies 1
- Other 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 12 |
| Smoke Deficiencies | 5 |
| Miscellaneous Deficiencies | 3 |
| Egress Deficiencies | 1 |
| Services Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 15, 2021 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (August 18, 2021) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (August 18, 2021) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (August 18, 2021) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (August 18, 2021) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (August 18, 2021) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 5, 2021) |
| K-0932 | Meet other general requirements. | Deficient, Provider has date of correction (August 5, 2021) |
May 9, 2019 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (June 17, 2019) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (June 17, 2019) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (June 17, 2019) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (June 17, 2019) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (June 17, 2019) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (June 17, 2019) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (June 17, 2019) |
| K-0222 | 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. | Deficient, Provider has date of correction (March 11, 2020) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 11, 2020) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 11, 2020) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (March 11, 2020) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (March 11, 2020) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (March 11, 2020) |
| K-0918 | Have 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
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 11, 2017) |
| K-0372 | Ensure 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.