Norfolk Health Care Center
Inspection Findings
F-Tag F0725
F 0725 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
Resident #190 was admitted to the facility on [DATE REDACTED] 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 REDACTED]. 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 REDACTED] at approximately 9:30 a.m., an interview was conducted with RN #3, who stated that she was scheduled for work on [DATE REDACTED] 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 REDACTED]. The DON was issued a Corrective Action form that read as follows:
On [DATE REDACTED], 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 REDACTED], 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 REDACTED], during the end-of-day meeting, the Administrator was made aware of the concerns, and no further information was provided.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Norfolk Health Care Center
901 East Princess Anne Road Norfolk, VA 23504
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
Norfolk Health Care Center in NORFOLK, VA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NORFOLK, VA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Norfolk Health Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.