Inspection Reports for Nans Pointe Rehabilitation and Nursing
200 W Constance Rd, Suffolk, VA 23434, United States, VA, 23434
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Inspection Report
Renewal
Census: 16
Deficiencies: 6
Oct 2, 2025
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and regulations for facility licensing renewal.
Findings
The inspection identified multiple violations including failure to maintain required tuberculosis (TB) assessments for staff and residents, lack of posted CPR/first aid certification listings, incomplete health care oversight documentation, improper labeling of over-the-counter medications, and failure to have an annual fire inspection on file.
Deficiencies (6)
| Description |
|---|
| Failure to maintain initial and annual tuberculosis (TB) risk assessments in staff records. |
| Failure to post a current listing of staff with CPR and first aid certification. |
| Failure to have a physical examination including TB risk assessment within 30 days prior to resident admission. |
| Failure to provide health care oversight by a licensed health care professional at least every six months. |
| Over-the-counter medications were not labeled with resident names as required. |
| Failure to have an annual fire inspection completed and documented as required by the Virginia Statewide Fire Prevention Code. |
Report Facts
Number of residents present: 16
Number of resident records reviewed: 3
Number of staff records reviewed: 2
Number of resident interviews conducted: 3
Number of staff interviews conducted: 5
Date of staff #1 hire: Apr 12, 2024
Date of resident #1 admission: Jul 19, 2025
Date of last fire inspection on file: Dec 12, 2023
Inspection Report
Monitoring
Census: 15
Deficiencies: 3
Mar 31, 2025
Visit Reason
An unannounced monitoring inspection was conducted on March 31, 2025 and April 22, 2025 following a self-report received on March 14, 2025 regarding allegations in the areas of Personnel and Resident Care and Related Services.
Findings
The investigation supported some but not all allegations, specifically substantiating verbal abuse by a staff member towards a resident, failure to update fall risk ratings after falls, and incomplete individualized service plans. A violation notice was issued and corrective actions were planned.
Complaint Details
The visit was not complaint-related but was triggered by a self-report received on 03/14/2025 regarding allegations in Personnel and Resident Care and Related Services. The evidence supported some allegations, including substantiated verbal abuse.
Deficiencies (3)
| Description |
|---|
| Facility failed to ensure all staff were considerate and respectful of the rights, dignity, and sensitivities of residents, substantiated verbal abuse by staff towards resident. |
| Facility failed to ensure the fall risk rating was reviewed and updated after a fall. |
| Facility failed to ensure the comprehensive individualized service plan (ISP) was completed within 30 days after admission and included a description of identified needs based on the UAI. |
Report Facts
Number of residents present: 15
Number of resident records reviewed: 1
Number of staff records reviewed: 2
Number of interviews conducted with residents: 1
Number of interviews conducted with staff: 3
Number of documented falls for resident #1: 5
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 2
Feb 11, 2025
Visit Reason
An unannounced complaint inspection was conducted following a complaint received on 2025-02-07 regarding allegations in the area of Resident Care and Related Services.
Findings
The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services and Staffing and Supervision. Violations included failure to ensure written communication among staff and failure to document resident condition changes and corresponding actions.
Complaint Details
Complaint related: Yes. The evidence gathered supported some but not all allegations related to Resident Care and Related Services and Staffing and Supervision.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure a method of written communication to keep direct care staff informed of significant happenings or problems experienced by residents, including complaints and incidents or injuries. |
| Facility failed to regularly observe each resident for changes in condition and document any notable changes and corresponding actions taken in the resident's record. |
Report Facts
Residents present: 17
Resident records reviewed: 2
Staff interviews conducted: 4
Resident interviews conducted: 3
Inspection Report
Renewal
Census: 19
Deficiencies: 5
Oct 1, 2024
Visit Reason
An unannounced renewal inspection was conducted to assess compliance with applicable standards and laws for facility licensing renewal.
Findings
The inspection identified multiple violations including failure to maintain current tuberculosis evaluations in staff records, incomplete preliminary plans of care for residents, unsigned individualized service plans, improper medication storage, and incomplete medication administration records.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure health information including current annual tuberculosis risk assessments were maintained in staff records. |
| Facility failed to develop a preliminary plan of care on or within 7 days prior to admission for resident #1. |
| Individualized service plans (ISP) for residents #1 and #2 were not signed and dated by required parties. |
| Medications were stored in an unlocked office in a plastic bag, not in a locked area as required. |
| Medication Administration Record (MAR) for resident #2 lacked staff initials and reasons for medication omissions on specified dates. |
Report Facts
Number of residents present: 19
Number of resident records reviewed: 2
Number of staff records reviewed: 2
Number of interviews conducted with residents: 2
Number of interviews conducted with staff: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Conducted the inspection and documented findings |
| Staff #2 | Named in tuberculosis evaluation and medication record deficiencies | |
| Staff #3 | Provided information regarding medication storage during inspection |
Inspection Report
Monitoring
Census: 17
Deficiencies: 7
Jun 26, 2024
Visit Reason
An unannounced monitoring inspection was conducted to review compliance with applicable standards and laws for the assisted living facility.
Findings
The inspection found multiple violations related to resident disclosure statements, admission documentation, resident agreements, orientation procedures, and medication management. The facility failed to update documents to reflect a change in ownership and did not ensure timely medication administration.
Deficiencies (7)
| Description |
|---|
| Facility failed to ensure disclosure statements included the new name of the facility and licensee for residents #1 through #6. |
| Resident #1's record did not contain written assurance that the facility had the appropriate license to meet care needs at admission. |
| Resident #1's record lacked documentation of a physical examination within 30 days prior to admission. |
| Resident #1's admission agreement did not include the licensee or administrator's signature. |
| Residents #2 through #6 original agreements were not updated to reflect the new facility name and licensee after ownership change. |
| Facility failed to provide orientation documentation for residents #1 through #6 including emergency procedures and call system use. |
| Medication for resident #4 (Magnesium Oxide Supplement) was not available and not administered as ordered. |
Report Facts
Number of residents present: 17
Number of resident records reviewed: 6
Number of staff records reviewed: 3
Number of resident interviews: 2
Number of staff interviews: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donesia Peoples | Licensing Inspector | Inspector conducting the monitoring inspection |
| Staff #2 | Confirmed issues with disclosure statements and resident records | |
| Staff #4 | Involved in medication pass observation where medication was missing |
Inspection Report
Original Licensing
Census: 16
Deficiencies: 0
Apr 2, 2024
Visit Reason
An announced mandated initial licensing inspection was conducted at the facility on April 2, 2024.
Findings
The inspection found no violations with applicable standards or laws. The licensing inspector toured the physical plant including buildings and grounds and confirmed resident rooms and floor plans.
Report Facts
Number of resident records reviewed: 0
Number of staff records reviewed: 0
Number of interviews conducted with residents: 0
Number of interviews conducted with staff: 2
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