Norfolk Health Care Center

In the surveyor’s words

From the most serious findings on record at Norfolk Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF725Sep 24, 2025

  Based on staff interviews, Facility documentation reviews, and clinical record reviews, the facility staff failed to ensure competent Professional nursing staff oversight, assessment, and administration of tracheostomy care for three residents (Resident #185, #186, and #190) in a survey sample of 60 Residents, resulting in Immediate Jeopardy. After accepting the plan to remove the immediacy from the Administrator and confirming that the Immediate Jeopardy was removed, the deficiency was assigned a Scope and Severity level of 3 (G), isolated (harm).The findings included: 1. […]

• Actual harm, isolatedF697Feb 16, 2023

  Based on resident interviews, family interviews, staff interviews, and clinical record review, the facility staff failed to manage pain by adhering to the prescribed medication regimen for two (2) of eight (8) residents (Resident #6 and #7), in the survey sample which resulted in unnecessary severe pain and constituted harm for both residents. The findings include: 1. The facility's staff failed to procure and administer Resident #6's scheduled pain medication Methadone HCL, for chronic pain which resulted in the resident missing multiple consecutive doses and experiencing such severe pain (8.5 to 9.0 out of a pain scale from ,d+[DATE]), which affected her day-to-day activities and ability to sleep. […]

• No harm, potential for more than minimal, widespreadF925Jul 15, 2021

  Based on general observations of the facility, staff and resident interviews, the facility staff failed to maintain an effective pest control program. Roaches were identified during the survey and recorded sightings by staff on all four floors (three resident units and first floor kitchen and common areas). The findings included: The pest sighting log sheets on all four floors identified roaches. Specifically, a review of the last 6 months on the first floor revealed roaches inside the dietary food cart, baseboard dish room, food tray and activities depart. A review of the last 6 months on the second floor revealed roaches in general areas, room 222, 227, soiled utility room and roaches everywhere in hallway. […]

• No harm, potential for more than minimal, patternF803Jan 14, 2026

  Based on observations, resident and staff interviews, and clinical record review, the facility staff failed to ensure that 3 of 28 residents (Residents #108, #107, and #124) in the survey sample had meals served that followed the menu and meal tickets. The findings included: 1. The facility's staff failed to serve food items according to the menu and meal ticket. Resident #108 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included stroke, renal failure, and heart failure. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/13/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. […]

• No harm, potential for more than minimal, patternF807Sep 24, 2025

  Based on observations, resident and staff interviews, and clinical record review, the facility staff failed to ensure that 3 of 28 residents (Residents #108, #107, and #124) in the survey sample received fluids as listed on the menu, per their preferences, or as ordered. The findings included: 3.The facility staff failed to serve a beverage listed on the menu. Resident #124 was originally admitted to the facility 3/03/17 from an acute care facility and re-admitted on [DATE]. The current diagnoses included; Dysphagia, Mechanically Altered PO Intake and Cerebral Palsy. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/03/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. […]