Cycle 1
Health 2021-11-11 · Fire 2021-11-11
21 health deficiencies
Top issue: Environmental (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Norfolk, VA
Ghent Health and Rehabilitation
1-star overall rating with 1-star inspections with abuse icon flag with 21 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3900 Llewellyn Ave, Norfolk, VA
(757) 625-5363
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
222
Certified beds
Average residents
168
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avardis Health
Operator or chain grouping
Approved since
1993-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.28
Registered nurse staffing
LPN hours / resident day
0.76
Licensed practical nurse staffing
Aide hours / resident day
1.66
Nurse aide staffing
Weekend hours
2.26
Weekend nurse staffing
RN turnover
47%
Annual RN turnover
Total nurse turnover
53%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.4% |
91.2%
15.8 pts worse
|
93.4%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.4% |
94.0%
7.6 pts worse
|
95.5%
9.1 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.6%
2.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
15.7%
12.1 pts better
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 9.4% |
5.7%
3.7 pts worse
|
5.4%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.5% |
20.2%
6.7 pts better
|
19.6%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 24.8% |
15.0%
9.8 pts worse
|
16.7%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.3% |
17.5%
5.2 pts better
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
15.7%
2.1 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.1% |
1.6%
1.5 pts better
|
1.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.6% |
22.2%
0.6 pts better
|
19.8%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
5.2%
0.5 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 31.1% |
74.6%
43.5 pts worse
|
81.7%
50.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.8% |
11.7%
3.1 pts worse
|
12.0%
2.8 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.6% |
1.2%
2.4 pts worse
|
1.6%
2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 26.8% |
73.6%
46.8 pts worse
|
79.7%
52.9 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.3% |
22.0%
10.7 pts better
|
23.9%
12.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-02-19 · Fire 2019-02-19
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2017-06-08 · Fire 2017-06-08
13 health deficiencies
Top issue: Administration (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2021-11-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-03-01
D · Potential for more than minimal harm
2021-11-11
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2022-03-01
F · Potential for more than minimal harm
2017-06-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2017-08-31
F · Potential for more than minimal harm
2017-06-08
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2017-08-31
F · Potential for more than minimal harm
2017-06-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2017-08-31
E · Potential for more than minimal harm
2017-06-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2017-08-31
E · Potential for more than minimal harm
2017-06-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2017-10-31
E · Potential for more than minimal harm
2017-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2017-08-31
E · Potential for more than minimal harm
2017-06-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2017-08-31
E · Potential for more than minimal harm
2017-06-08
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2017-08-31
E · Potential for more than minimal harm
2017-06-08
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2017-08-31
E · Potential for more than minimal harm
2017-06-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2017-08-31
D · Potential for more than minimal harm
2017-06-08
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2017-08-31
D · Potential for more than minimal harm
2017-06-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2017-08-31
D · Potential for more than minimal harm
2017-06-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2017-08-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-07-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-07-19
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-19
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-08-30
J · Immediate jeopardy
2023-03-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-07
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-07
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-07
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-07
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-03-24
G · Actual harm
2021-11-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-12-26
F · Potential for more than minimal harm
2021-11-11
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2021-12-26
F · Potential for more than minimal harm
2021-11-11
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2021-12-26
E · Potential for more than minimal harm
2021-11-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-12-26
E · Potential for more than minimal harm
2021-11-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-12-26
E · Potential for more than minimal harm
2021-11-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-12-26
E · Potential for more than minimal harm
2021-11-11
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-12-26
E · Potential for more than minimal harm
2021-11-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-26
E · Potential for more than minimal harm
2021-11-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-12-26
E · Potential for more than minimal harm
2021-11-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-26
E · Potential for more than minimal harm
2021-11-11
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-11
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-11
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-11
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-11
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-11
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2021-12-26
C · Minimal harm
2021-11-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-12-26
G · Actual harm
2019-02-19
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-04-06
E · Potential for more than minimal harm
2019-02-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2019-05-13
E · Potential for more than minimal harm
2019-02-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-04-06
E · Potential for more than minimal harm
2019-02-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-04-06
E · Potential for more than minimal harm
2019-02-19
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-04-06
E · Potential for more than minimal harm
2019-02-19
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2019-04-06
E · Potential for more than minimal harm
2019-02-19
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2019-04-06
D · Potential for more than minimal harm
2019-02-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-04-06
D · Potential for more than minimal harm
2019-02-19
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2019-04-06
D · Potential for more than minimal harm
2019-02-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-04-06
D · Potential for more than minimal harm
2019-02-19
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-04-06
D · Potential for more than minimal harm
2019-02-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-04-06
D · Potential for more than minimal harm
2019-02-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-04-06
D · Potential for more than minimal harm
2019-02-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-05-13
D · Potential for more than minimal harm
2019-02-19
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2019-04-06
D · Potential for more than minimal harm
2019-02-19
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2019-04-06
D · Potential for more than minimal harm
2019-02-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-13
E · Potential for more than minimal harm
2017-06-08
F151 · Resident Rights Deficiencies
Health
Honor a residents' rights as a residents of the nursing home, free of coercion and reprisal, and as citizens or residents of the United States.
Corrected 2017-07-14
E · Potential for more than minimal harm
2017-06-08
F280 · Resident Assessment and Care Planning Deficiencies
Health
Allow residents the right to participate in the planning or revision of care and treatment.
Corrected 2017-07-14
D · Potential for more than minimal harm
2017-06-08
F157 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2017-07-14
D · Potential for more than minimal harm
2017-06-08
F315 · Quality of Life and Care Deficiencies
Health
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
Corrected 2017-07-14
D · Potential for more than minimal harm
2017-06-08
F372 · Environmental Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2017-07-14
D · Potential for more than minimal harm
2017-06-08
F431 · Pharmacy Service Deficiencies
Health
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Corrected 2017-07-14
C · Minimal harm
2017-06-08
F253 · Environmental Deficiencies
Health
Provide housekeeping and maintenance services.
Corrected 2017-07-14
Penalties and ownership
What sits behind the stars
Ownership
Norfolk Parentco LLC
5% Or Greater Direct Ownership Interest · Organization
Hajimomenian, Amir
Operational/Managerial Control · Individual
Hoback, Tiffany
Operational/Managerial Control · Individual
Jones, Tequilla
Operational/Managerial Control · Individual
Jurolien, Cynthia
Operational/Managerial Control · Individual
Kintyhtt, Jennifer
Operational/Managerial Control · Individual
Mermaid Parade Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Morgan, Daniel
Operational/Managerial Control · Individual
Nu C Ii Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Nu C Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Ohi Assets (Va) Norfolk - 3900 Llewellyn, LLC
5% Or Greater Security Interest · Organization
Snf Care Centers LLC
5% Or Greater Indirect Ownership Interest · Organization
Snf Mgr LLC
Operational/Managerial Control · Organization
Vaop Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Zenith Holdco Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Zenith Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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Signature Healthcare Of Norfolk
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2-star overall rating with 2-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Norview Heights Rehabilitation And Nursing
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2-star overall rating with 3-star inspections with 11 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Norfolk Health Care Center
Norfolk, VA
1-star overall rating with 2-star inspections with $157,300 in total fines with 23 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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