Ghent Health And Rehabilitation
Ghent Health and Rehabilitation in NORFOLK, VA — inspection on February 26, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
President of Operations, and the Corporate Nurse Consultant.
The above findings were conveyed to
Resident #58 was admitted to the facility on [DATE].
The resident's diagnoses included a stroke,
assessment reference date (ARD) of 12/24/25, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 14 out of 15.
This indicated that Resident #58's cognitive abilities for daily decision-making were intact. On 2/3/26 at approximately 3:59 PM, Resident #58 was observed seated on his bed wearing a navy blue puffer jacket.
The resident stated that he and his brother were sharp dressers while growing up in [NAME], and that not having his personal clothing was extremely difficult.
The resident stated that all his coats were missing, and he was afraid to remove the one he was wearing because it might be lost. On 2/6/26 at 10:15 AM, an observation was made of him having his face shaved and his hair cut in his room. At approximately 11:05 AM, the resident was observed coming out of the shower room. He stated that he had enjoyed a warm shower and was returning to his room for lunch. On 2/6/26 at approximately 11:55 AM, an interview was conducted with Resident #58 regarding his missing clothing, with the Assistant Director of Nursing (ADON) present.
The ADON assured the resident that a staff member would make every effort to locate his missing coats and return the items to him. On 2/11/26 at approximately 5:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations, and the Corporate Nurse Consultant.
The above findings were conveyed to the administrative team, who made no comments and expressed no concerns.
495273 02/26/2026
Ghent Health and Rehabilitation 3900 Llewellyn Ave Norfolk, VA 23504
punishment, and neglect by anybody.
resident and staff interviews, a review of the clinical record, and facility documents, the facility staff
(Resident #3) in the survey sample.
The findings included: Resident #3 was initially admitted to the facility on [DATE] from a community home.
The residents' diagnoses included dementia, a psychotic disorder, and an anxiety disorder.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/9/26, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 12 out of 15.
This indicated Resident #3's cognitive abilities for daily decision making were intact. In section GG0130. (Self-Care), The resident was coded as requiring setup or clean-up assistance with eating, partial/moderate assistance with upper and lower body dressing, and putting on footwear, dependent on toileting, oral hygiene, and showers/baths.A review of facility documents revealed that Certified Nursing Assistant (CNA) #10 was verbally and physically abusive to Resident #3 on 4/16/25 during and after a shower. A report was filed alleging that CNA #10 called the resident a witch multiple times and, while traveling in the corridor after her shower, rolled the resident in front of a fan, causing her to yell due to discomfort from the cold air.An interview was conducted with the Resident #3 on 2/10/26 at 9:24 AM.
The resident stated that no staff member mistreated her.
The resident also stated she has a bad temper and is very vocal, which irritates people. On 2/10/26 at 9:53 AM, an interview was conducted with CNA #9. CNA #9 stated that Resident #3 takes showers without conflict.
She stated that the resident will say I'm cold during care.
CNA #9 further stated that the resident is not aggressive but becomes impatient during care.On 2/10/26 at 9:58 AM, an interview was conducted with Licensed Practical Nurse (LPN) #8. LPN #8 stated that whenever there is an allegation of abuse anywhere in the facility, all staff are educated on abuse, and at least once per year, they have to complete the abuse in-service. LPN #8 stated that the resident is often difficult to care for and that, at times, two staff members are required to provide her care. LPN #8 stated that she instructs the CNA staff that, whenever behaviors are exhibited, they should ensure the resident is safe, step away, report the behaviors to the nurse, and return later.The facility conducted the following actions after the allegation was voiced.
The resident was interviewed and assessed for further abuse.
The resident was referred for psychological services for her psychosocial well-being.
All other residents the employee had cared for were interviewed and/or assessed for indications of abuse.
Staff training on abuse was validated by signatures.
The employee was suspended during the investigation and later terminated.
The allegation and finding were reported to the state agency. A further review revealed the staff member had no criminal past and she had completed two abuse in-services over the year. No current findings of abuse were identified during the survey.On 2/11/26 at approximately 5:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Regional [NAME] President, and the Corporate Nurse Consultant.
The above findings were conveyed to the administrative team, who made no comments and voiced no concerns.
495273 02/26/2026
Ghent Health and Rehabilitation 3900 Llewellyn Ave Norfolk, VA 23504
Review of facility documents failed to evidence that an incident report and investigation was conducted by the facility regarding the incident on 10/27/2023. On 02/11/2026 at approximately 8:12 a.m. an interview was conducted with the facility's Administrator (ADM) regarding the procedure for completing a facility related incident (FRI).
She stated that a FRI is initiated by her when there is an incident outside of daily operations such as a resident-to-resident altercation, staff-to-resident altercation, allegations of abuse, neglect or mistreatment, injury of unknown origin, etc The ADM stated that she notifies the Ombudsman, APS (adult protective services), the state agency (office of licensure and certification) and the police if necessary of the alleged allegation and then initiates an investigation that includes interviews with the parties involved and obtains witness statements and review of the resident's clinical record if necessary.
The ADM stated that she has five days to complete the investigation and send her findings to the parties listed above.
She also stated that if there is an allegation of abuse the investigation needs to be initiated within two hours of being informed of the allegation.
Regarding the allegation of R170 threatening a resident with a knife she stated that she could not locate a facility investigation and further stated that an investigation should have been initiated.
The facility's policy Compliance with Reporting Allegations of Abuse/Neglect/Exploitation documented in part, It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. On 02/11/2026 at approximately 4:40 p.m., ASM, the DON and the Regional Director, were made aware of the above findings. No further information was provided prior to exit.
References:(1) The symptom of paralysis that mainly affects your legs.
This information was obtained from the website: https://my.clevelandclinic.org/health/symptoms/23984-paraplegia.
495273 02/26/2026
Ghent Health and Rehabilitation 3900 Llewellyn Ave Norfolk, VA 23504
MedlinePlus Drug Information
Resident #137 (R137).
R137 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ICH (intracranial hemorrhage) DM (diabetes mellitus) and TIA (transient ischemic attack).
R137's most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/2/26, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as maximal assist for bed mobility, transfer, hygiene.
A review of R137's comprehensive care plan dated 1/29/26 revealed, FOCUS: The resident has an ADL (activity of daily living) self-care performance deficit related to impaired mobility.
INTERVENTIONS: Praise all efforts at self-care.
A review of the physician's order dated 1/26/26 revealed, Fluid Restriction - 1420cc / day.
A review of the January and February 2026 MAR-TAR (medication administration record-treatment administration record) did not evidence any fluid restriction monitoring.
A review of R137's meal slips did not reveal any evidence of fluid restriction monitoring.
An interview was conducted on 2/5/26 at 9:30 AM with R137, when asked if he is on a fluid restriction, R137 stated, not that I know of.
An interview was conducted on 2/5/26 at 1:30 PM with LPN (licensed practical nurse) #3, when asked what steps are taken to monitor a fluid restriction, LPN #3 stated, we would watch what his intake was.
Asked the purpose of the care plan, LPN #3 stated to identify the interventions needed to care for each resident.
Asked if the fluid restriction should be on the care plan, LPN #3 stated, yes, it should.
On 2/9/26 at 5:00 PM the administrator and the director of nursing, RN (registered nurse) was made aware of the concerns.
No further information was provided prior to exit.
495273 02/26/2026
Ghent Health and Rehabilitation 3900 Llewellyn Ave Norfolk, VA 23504
assistant) #3 regarding hygiene care for R169.
She stated that she did not recall R169.
She also
resident has received hygiene and ADL (activities of daily living) care she stated that it is
sheet for R169's personal hygiene listed above she stated that she did not know what the blanks indicated.
On 02/10/2026 at approximately 9:25 a.m. an interview was conducted with RN (registered nurse) #1 regarding hygiene care for R169.
When asked about providing hygiene care to a resident she stated the resident has their hair and face washed, hair combed, fingernails cleaned and trimmed if needed, showers or bed baths and incontinent care if needed.
When asked how it is evidenced that a resident has received hygiene and ADL care she stated that it is documented in PCC.
On 02/11/2026 at approximately 4:40 p.m., the administrator, DON and the Regional Director, were made aware of the above findings.
No further information was provided prior to exit.
Reference: (1) A mental condition that causes both a loss of contact with reality [psychosis] and mood problems [depression or mania].
This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/000930.htm.
495273 02/26/2026
Ghent Health and Rehabilitation 3900 Llewellyn Ave Norfolk, VA 23504
Review of the electronic treatment administration record (eTAR) for R173 dated 3/1-3/31/2024 failed to evidence any treatments completed.
The comprehensive care plan for R173 documented in part, [R173] actual impaired skin to Lower back r/t (related to) Laminectomy.
Date Initiated: 04/01/2024. On 2/9/2026 at 9:42 AM, an interview was conducted with registered nurse (RN) #2 who stated that when a resident was admitted a full body skin assessment was completed to identify any wounds.
She stated that she did not remember R173 but if they came in with a surgical wound they would remove the dressing to assess the site unless they came with an order from the physician to not remove the dressing. RN #2 stated that the wound assessment was documented in the clinical record and treatment orders were entered as sent from the surgeon or obtained from the facility physician. On 2/9/2026 at 2:14 PM, an interview was conducted with licensed practical nurse (LPN) #1, the unit manager, who stated that the admission nurse completed a head-to-toe skin assessment on each resident when they arrived.
LPN #1 stated that any wounds should be identified on admission and treatment orders were obtained either from the hospital discharge summary or from the facility physician or nurse practitioner.
She stated that any resident admitted with a surgical wound should have either a treatment in place or an order to not remove the dressing. On 2/9/2026 at 3:02 PM, an interview was conducted with the director of nursing (DON) who stated that normally they knew if resident had a surgical wound and treatment before they were admitted to the facility.
She stated that the hospital normally advised them to leave a dressing in place or gave treatment orders and there would be orders placed in the medical record either way to alert staff.
The DON stated that she would expect staff to contact the surgeons office or the case worker at the hospital to see what the treatment to the surgical wound should be and ideally have this in place prior to the resident arriving.
The facility policy Skin Assessment revised 11/7/2025 documented in part, .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter .
On 2/10/2026 at approximately 4:37 PM, the administrator and DON were made aware of the concern.
No further information was provided prior to exit.
495273 02/26/2026
Ghent Health and Rehabilitation 3900 Llewellyn Ave Norfolk, VA 23504
residents who require such services, consistent with professional standards of practice, the
information was provided prior to exit.
Reference:(1) Hydrocodone is available in combination with
hydrocodone combination products are used to relieve severe pain .
This information was obtained from the website: Hydrocodone Combination Products: MedlinePlus Drug Information
495273 02/26/2026
Ghent Health and Rehabilitation 3900 Llewellyn Ave Norfolk, VA 23504
During observation at 4:00 PM, there was no observation of mouse on glue pad and no glue pad in room.
Unable to locate any staff who may have removed mice.
On 2/6/26 at 10:25 AM, an interview was conducted with OSM #3, the pest control representative.
Asked about pest control for the facility, OSM #3 stated, they are on three times a week schedule.
For rodent control we do traps in non-public areas and glue boards.
Baiting in patient rooms and resident areas. We review the pest sighting logs and identify any other areas to treat.
On 2/6/26 at 11:50 AM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings.
A review of the facility's Pest Control Program policy revealed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.
No further information was provided prior to exit.
- The facility staff failed to eradicate roaches from the environment.
During the survey, observations were conducted in Unit 1B from 2/3/26 through 2/6/26 and from 2/9/26 through 2/11/26 because most interviewable residents reported roaches and mice in their rooms.
On 2/4/26, a large brown roach was observed in the corridor lying on its back with its legs wiggling.
On 2/6/26 at approximately 11:40 AM, while making observations of the unit with the Assistant Director of Nursing (ADON), a small dark colored roach was observed crawling quickly on the toilet seat in the bathroom of room [ROOM NUMBER].
The ADON closed the bathroom door and stated she would document the sighting on the pest control log.
On 2/11/26 at approximately 5:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, [NAME] President of Operations, and the Corporate Nurse Consultant.
The above findings were conveyed to the administrative team, who made no comments and voiced no concerns.