Signature Healthcare of Norfolk

In the surveyor’s words

From the most serious findings on record at Signature Healthcare of Norfolk, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF557Jul 21, 2023

  Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity by not ensuring the residents' rights to retain personal possessions for two of two sampled residents (Residents (R)52 and R82) reviewed for resident rights. This failure had the possibility to have a negative impact on numerous residents residing in the facility. Findings include: Review of R52's Face Sheet, located under the Profile tab of the electronic medical record (EMR) revealed R52 was admitted to the facility on [DATE] with diagnoses which included flaccid hemiplegia affecting the left non dominant side, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, heart failure, type II diabetes, major depressive disorder, major… […]

• No harm, potential for more than minimal, patternF623Jul 21, 2023

  Based on record review, interviews, and facility policy review, the facility failed to ensure residents received written discharge notices at the time of transfer to the hospital for four (Resident (R)119, R15, R64, and R70) of six residents reviewed for hospitalization . Findings include: Review of the facility's policy titled, Transfer/Discharge Notice dated 11/01/22 revealed for the Emergent Transfers to Acute Care section, the facility will send a written notice of discharge to the resident and/or resident representative when the resident was transferred/discharged to the hospital. 1. […]

• No harm, potential for more than minimal, patternF657Jul 21, 2023

  Based on family interview, staff interviews, clinical record review and facility documentation review the facility staff failed to invite 1 out of 50 resident (Resident #46) or their Responsible Representative (RR) to attend their person-centered care plan meeting. The findings included: Resident #46 was originally admitted to the nursing facility on 05/14/21. Diagnosis for Resident #46 included but not limited to acute subdural hemorrhage, dementia with behavioral disturbance and anxiety. The Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date (ARD) of 04/28/23 coded Resident #46 with a 03 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF760Jul 21, 2023

  Based on staff interviews, clinical record review and facility document review, the facility staff failed to ensure 1 of 59 residents (Resident #236) in the survey sample were free of significant medication errors. The findings included: The facility staff failed to ensure the significant medication Lopressor (used to treat high blood pressure) 25 mg was administered twice a day to Resident #326 from 11/14/20 through 11/20/20. Resident #236 was admitted to the facility on [DATE] and transferred to an acute care setting on 11/24/20. The resident did not return to the nursing facility. Diagnosis included but are not limited to Congestive Heart Failure (CHF) and Hypertension (high blood pressure). […]

• No harm, potential for more than minimal, isolatedF580Jul 21, 2023

  Based on staff interviews, clinical record review, and facility documentation, the facility staff failed to immediately inform the physician of the need to assess/evaluate, start, or alter treatment when there was a significant deterioration in the resident's condition for 1 of 59 residents (Resident #46) in the survey sample. The findings included: Resident #46 had four (4) falls between 04/24/23 - 05/22/23 and during that time she had behavioral and neurological changes. She was at risk for major injury related to being on an anticoagulation medication (blood thinner), independent with ambulation, and a diagnosis of dementia. The resident was not assessed after significant behavioral and neurological changes were identified. […]