Norfolk Health Care Center
Norfolk Health Care Center in NORFOLK, VA — inspection on September 24, 2025.
Found 1 citation. 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
jeopardy to resident health or safety
Resident #190 was admitted to the facility on [DATE] with diagnoses including but not limited to acute encephalopathy, anemia in chronic kidney disease stage 5, atherosclerosis of arteries, hypertension, chronic pain, continuous opioid dependence, dysphagia, end stage renal failure on dialysis, type 2 diabetes, anoxic brain damage, subclavian and axillary DVT (Deep Vein Thrombosis) chronic respiratory failure. Resident #190 had a tracheostomy and a g tube, was non-verbal, in a chronic vegetative state, and totally dependent on staff for all aspects of care. Resident #190 was coded as a DNR (Do Not Resuscitate) and on palliative care.
A review of the staffing worksheet revealed that RN #3 was scheduled to work the 7:00 p.m. – 7:00 a.m. shift on the 2nd floor tracheostomy unit on [DATE]. A review of the timecard punches revealed RN #3 clocked in at 6:59 p.m. and that she clocked out at 8:47 p.m.
On [DATE] at approximately 9:30 a.m., an interview was conducted with RN #3, who stated that she was scheduled for work on [DATE] and that she was a new RN and a new employee at the facility.
She stated that she was still in training and that it would have been her first night working on the tracheostomy unit.
She stated that after clocking in, she heard the staff discussing the people who had called out, including the RN supervisor.
She stated that she suddenly realized she would be the only RN on the specialized tracheostomy unit responsible for the entire unit, which she had never worked before, and as a new nurse, she had not had much experience with tracheostomies.
She stated that she began to get nervous about what could happen, and she called the supervisor, and they called the DON (Director of Nursing), who refused to come in.
She stated that at that point, she was worried about what could happen if something went wrong.
She stated that she did not feel comfortable taking the assignment, so she handed the keys over, clocked out, and went home at 8:47 pm.
A review of the facility records revealed that the DON did, in fact, refuse to come to the facility on the night of [DATE].
The DON was issued a Corrective Action form that read as follows: On [DATE], you failed to ensure there was adequate nurse coverage after being informed of the callouts on the unit.
You were also instructed that a member from the nursing leadership needed to come into the center, and no one did.
A review of the staffing revealed that there was no RN coverage on the specialized tracheostomy unit when Resident #190 was found deceased .
The RN from another floor had to be called down to pronounce Resident #190's death, as there were only LPNs working the specialized unit.
On [DATE], an interview was conducted with the Administrator, who stated that she was aware that a Registered Nurse was required to be scheduled on all shifts on the specialized tracheostomy unit.
On [DATE], during the end-of-day meeting, the Administrator was made aware of the concerns, and no further information was provided.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Norfolk Health Care Center
901 East Princess Anne Road Norfolk, VA 23504
SUMMARY STATEMENT OF DEFICIENCIES