Inspection Reports for
Nans Pointe Rehabilitation and Nursing
200 W Constance Rd, Suffolk, VA 23434, United States, VA, 23434
Back to Facility Profile4 Reports · 1 Summary
Inspection Summary
7 inspections covered, Apr 2024 – Jan 2026.
Inspection Reports Summary
Visit Reason
This report covers 7 inspections of Nans Pointe Rehabilitation and Nursing LLC from April 2, 2024 to January 14, 2026, including complaint and renewal inspections.
Complaint Details
Two inspections were complaint surveys. The January 14, 2026 complaint inspection found no violations. The February 11, 2025 complaint inspection found violations related to resident care and staffing, including failure to document resident condition changes and communication failures.
Findings
Across that history VDSS cited 23 violations under 21 distinct standards. 5 of 7 visits ended with violations and 2 with none. 2 inspections were prompted by a complaint.
Violations (21)
22VAC40-73-320-A: Failed to ensure physical exam within 30 days preceding admission was on file.
22VAC40-73-680-G: Over-the-counter medications not labeled with resident's name until administered.
22VAC40-73-260-C: Failed to post listing of staff with current first aid or CPR certification.
22VAC40-73-250-D: Staff record missing initial and annual TB risk assessment documentation.
22VAC40-73-490-A: Failed to provide health care oversight at least every six months by licensed professional.
22VAC40-73-940-A: Failed to ensure annual fire inspection by appropriate official was completed.
22VAC40-73-110-1: Staff verbally abused resident; failed to ensure respectful treatment.
22VAC40-73-325-B: Fall risk rating not reviewed or updated after resident falls.
22VAC40-73-450-C: ISP did not include physical assistance needs for toileting as identified in UAI.
22VAC40-73-460-E: Failed to document actions taken for notable changes in resident's condition.
22VAC40-73-300-B: Failed to utilize written communication to keep staff informed of incidents.
22VAC40-73-250-D: Staff record missing current annual TB risk assessment documentation.
22VAC40-73-660-A: Medications stored unlocked in plastic bag, not consistent with standards.
22VAC40-73-680-I: MAR missing staff initials and/or reasons for medication omissions.
22VAC40-73-450-E: ISP not signed and dated by licensee/administrator and resident/legal representative.
22VAC40-73-450-A: Preliminary plan of care not developed on or within 7 days prior to admission.
22VAC40-73-310-D: Failed to provide written assurance of appropriate license to resident at admission.
22VAC40-73-50-A: Disclosure statements missing facility and licensee name after ownership change.
22VAC40-73-390-A: Admission agreement missing licensee or administrator's signature.
22VAC40-73-390-C: Original agreement not updated or signed after policy or information changes.
22VAC40-73-410-A: Orientation for new residents and legal guardians not documented as provided.
Report Facts
Violations cited: 23
Distinct standards: 21
Inspections on page: 7
Inspections with violations: 5
Complaint visits: 2
Individual Reports
One document per inspection visit.
Inspection Report — Oct 23, 2025
Complaint Investigation
Date: Oct 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on observations, staff interviews, and clinical record reviews related to multiple deficiencies including failure to post survey results, failure to administer ordered antibiotics, failure to notify physicians of abnormal lab results, failure to provide specialized rehabilitative services, and failure to maintain an infection prevention and control program.
Complaint Details
The complaint investigation revealed failures in posting survey results, medication administration, lab result notification, therapy service provision, and infection control practices. The findings were shared with facility leadership who had no additional comments or concerns.
Findings
The facility failed to post the most recent survey results in an accessible location, failed to administer ordered IV antibiotics to a resident with an infected diabetic ulcer, failed to promptly notify the physician of abnormal lab results, failed to provide timely specialized therapy evaluations resulting in delayed treatment, and failed to maintain an infection prevention and control program including proper cohorting and signage for residents at risk of infection transmission.
Violations (5)
Failed to post the most recent survey results in a place readily accessible to residents, family members, and legal representatives.
Failed to administer the ordered intravenous antibiotic to Resident #2 with an infected diabetic ulcer.
Failed to promptly notify the physician and/or practitioner of abnormal lab results for Resident #2.
Failed to provide a specialized therapy evaluation resulting in delayed treatment for Resident #3.
Failed to maintain an infection prevention and control program designed to limit opportunities for infection transmission, including failure to post Enhanced Barrier Precautions signage and improper cohorting.
Report Facts
Residents in survey sample: 4
Resident #2 BIMS score: 13
Resident #3 BIMS score: 9
Linezolid antibiotic dosage: 600
Linezolid antibiotic dosage reduced: 300
Right foot plantar wound size: 2.1
Right foot plantar wound size: 1.5
Right foot plantar wound size: 0.7
New tunneling: 0.9
Creatinine Clearance: 27
Therapy evaluation start dates: 9
Therapy evaluation start dates: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Interviewed regarding Resident #2's wound and antibiotic administration | |
| Director of Nursing (DON) | Participated in interviews and shared findings | |
| Corporate Consultant | Participated in interviews and shared findings | |
| President of Clinical Services | Participated in interviews and shared findings | |
| Director of Rehabilitation (DOR) | Interviewed regarding therapy evaluations and services for Resident #3 | |
| Licensed Practical Nurse (LPN) #3 | Interviewed regarding therapy screening and resident insurance | |
| Business Office Manager (BOM) | Interviewed regarding Resident #3's insurance status | |
| Minimum Data Set Coordinator (MDSC) | Interviewed regarding therapy orders and family decisions | |
| Social Worker (SW) | Mentioned in relation to Resident #3's therapy insurance issues | |
| Infection Preventionist (IP) | Consulted regarding cohorting and infection control signage | |
| Administrator | Participated in interviews and shared findings | |
| President of Operations | Participated in interviews and shared findings |
Inspection Report — Jul 12, 2022
Complaint Investigation
Date: Jul 12, 2022
Visit Reason
The inspection was conducted based on a complaint investigation regarding multiple concerns including failure to notify family of significant weight loss, failure to provide admission agreements, incomplete assessments, medication administration errors, unclean environment, and other regulatory compliance issues.
Complaint Details
This inspection was complaint-related and included multiple deficiencies identified through resident and staff interviews, clinical record reviews, and facility document reviews.
Findings
The facility was found deficient in multiple areas including failure to notify family of significant weight loss for a resident, failure to provide admission agreements, inaccurate resident assessments, medication administration errors including late and omitted medications, failure to maintain clean and sanitary environment, failure to maintain essential equipment, pest control deficiencies, failure to provide pneumococcal immunizations, failure to report COVID-19 data timely, and failure to have a designated infection preventionist with specialized training.
Violations (20)
Facility staff failed to notify family of significant weight loss for Resident #318.
Facility staff failed to provide Resident #317 with an admissions package including admission agreement, transfer/discharge agreement, and financial agreement.
Facility staff failed to ensure Resident #86 received a complete and accurate Minimum Data Set (MDS) assessment.
Facility staff failed to conduct a level I PASARR screening for Resident #30.
Facility staff failed to administer Resident #22's Lantus insulin as ordered by the physician, resulting in late administration.
Facility staff failed to administer Resident #84's morning medications on 4/14/22 as ordered.
Facility staff failed to provide accurate medication administration for Resident #68, including late administration of nighttime medications.
Facility staff failed to provide necessary fingernail care for Resident #3 who was dependent on staff for activities of daily living.
Facility staff failed to provide respiratory care in accordance with professional standards for Resident #323, including failure to complete oxygen assessment and specify oxygen flow rate.
Facility staff failed to provide pain management to Resident #267, including failure to administer scheduled narcotic analgesics and failure to obtain medications timely from pharmacy or medication system.
Facility staff failed to ensure Resident #319 received significant medications (Metoprolol Succinate and Eliquis) on 02/09/22 due to failure to pull medications from the Cubex system.
Facility staff failed to provide food that was palatable and attractive; lasagna served was burned and unappetizing.
Facility staff failed to maintain kitchen and food preparation areas in sanitary condition, including presence of grease, food particles, holes in walls, rusted electrical sockets, and malfunctioning dishwasher.
Facility staff failed to maintain an effective pest control program; live roaches observed in kitchen and structural deficiencies noted that allow pest entry.
Facility staff failed to present a QAPI plan and failed to conduct QAPI meetings for over a year to identify and correct quality deficiencies.
Facility staff failed to administer pneumococcal immunizations to 3 of 5 residents reviewed, including failure to offer revaccination as recommended.
Facility staff failed to inform residents, their representatives, and families of COVID-19 positive cases timely and weekly as required.
Facility staff failed to reduce risk of COVID-19 transmission by failing to test unvaccinated exempted staff at least weekly for over 30 days.
Facility staff failed to maintain cleaning equipment in good operational condition, including broken scrubber and buffer, resulting in unclean floors and environment.
Facility staff failed to staff a Registered Nurse for at least 8 consecutive hours a day, 7 days a week.
Report Facts
Residents in survey sample: 47
Resident #318 weight loss: 40
Resident #318 weight on 5/20/22: 161.2
Resident #318 weight on 4/21/22: 204
Resident #319 medication omission duration: 4
Resident #68 BIMS score: 12
Resident #86 BIMS score: 1
Resident #3 BIMS score: 3
Resident #7 BIMS score: 13
Resident #5 BIMS score: 8
Resident #268 BIMS score: 0
Resident #323 BIMS score: 12
Resident #22 Lantus insulin administration times: 8
Resident #68 pneumococcal immunization date: 2016
Resident #319 missed medication date: 2022
Facility RN staffing gap date: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Interviewed regarding Resident #316's leg swelling and Resident #318's weight loss notification. |
| LPN #5 | Unit Manager | Interviewed regarding Resident #318's weight loss notification and QA/QAPI meetings. |
| Dietician (OSM/Other Staff member #6) | Dietician | Interviewed regarding Resident #318's weight loss and diet downgrade. |
| Regional Admissions Director | Admissions Director | Confirmed Resident #317 was not provided with admission agreements. |
| MDS Coordinator #1 | MDS Coordinator | Interviewed regarding Resident #86's inaccurate MDS assessment. |
| LPN #6 | Licensed Practical Nurse | Interviewed regarding Resident #84's missed morning medications. |
| LPN #10 | Licensed Practical Nurse | Interviewed regarding late medication administration for Resident #68. |
| RN #4 | Registered Nurse | Interviewed regarding delayed medication delivery for Resident #267. |
| Director of Nursing (DON) | Director of Nursing | Interviewed multiple times regarding medication procurement issues, COVID-19 infection program, and QA/QAPI meetings. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control program, pneumococcal immunization, and COVID-19 notifications. |
| Assistant Maintenance Worker | Maintenance Worker | Interviewed regarding dishwasher malfunction and kitchen maintenance. |
| Dietary Manager | Dietary Manager | Interviewed regarding food quality, kitchen conditions, and trash maintenance. |
| LPN #7 | Licensed Practical Nurse | Interviewed regarding failure to pull medications from Cubex system for Resident #319. |
| LPN #9 | Licensed Practical Nurse | Interviewed regarding Resident #267's pain management and COVID-19 positive test. |
Inspection Report — May 16, 2019
Routine
Date: May 16, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs (call light accessibility), failure to send care plan summaries and bed hold notices upon hospital discharge, lack of PASRR screening for one resident, incomplete care plans for some residents, failure to obtain daily weights as ordered, improper oxygen administration, missed physician visits, inadequate RN coverage, unsanitary trash compactor areas, and lack of an antibiotic stewardship program.
Violations (11)
Facility staff failed to ensure a call bell system was in place that Resident #50 was capable of using to contact the staff.
Facility staff failed to send care plan summary goals for 4 residents when discharged to the hospital.
Facility staff failed to issue written Bed Hold Notices to 3 residents and/or Resident Representatives when discharged to the hospital.
Facility staff failed to issue a Preadmission Screening and Resident Review (PASRR) for 1 resident.
Facility staff failed to develop comprehensive care plans for two residents, including nutritional care and call light accessibility.
Facility staff failed to obtain daily weights per physician's order for Resident #7.
Facility staff failed to administer oxygen per physician's order for Resident #13.
Facility staff failed to ensure timely physician visits for Resident #44.
Facility staff failed to ensure Registered Nurse coverage for 8 hours on three days.
Facility staff failed to dispose of trash in a sanitary manner around trash and recycle compactors.
Facility staff failed to have an Infection Control and Prevention program which monitored all antibiotics administered by the facility staff.
Report Facts
Residents in survey sample: 56
Weight loss percentage: 10
Missing RN coverage days: 3
Physician visit gap: 4
Physician visit gap: 6
Weight documentation missing days: 4
Consecutive days same weight documented: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Noticed Resident #50's call light was not accessible and contacted Maintenance to install specialty call light |
| CNA #1 | Certified Nursing Assistant | Reported Resident #50's inability to use regular call light and frequent window opening |
| Director of Nursing | Director of Nursing | Acknowledged expectation for Resident #50 to have accessible call light and care plan; acknowledged failure to send care plan summaries and bed hold notices; stated plans to train staff and contact Medical Director regarding antibiotic stewardship |
| RN Unit Manager #6 | Registered Nurse Unit Manager | Reported documents sent upon discharge but unaware of sending care plan summaries or bed hold notices |
| LPN #1 | Licensed Practical Nurse | Interviewed about care plan development and daily weights process |
| LPN #5 | Licensed Practical Nurse | Resident #7's nurse, discussed weight documentation and process |
| LPN #3 | Licensed Practical Nurse | Resident #13's nurse, discussed oxygen administration and flow rate issues |
| OSM #3 | Medical Records Staff | Responsible for ensuring physician visits are timely and presenting physician visit documentation |
| OSM #4 | Dietician | Responsible for nutritional care plans, added Resident #44's nutrition care plan during survey |
| Other Staff #7 | Nursing Scheduler | Confirmed RN coverage gaps and staffing issues |
| ASM #1 | Administrator | Made aware of multiple deficiencies during exit |
Inspection Report — Aug 10, 2017
Complaint Investigation
Date: Aug 10, 2017
Visit Reason
The inspection was conducted as a complaint investigation based on allegations of misappropriation of resident medications, inaccurate Minimum Data Set (MDS) assessments, failure to post survey results properly, failure to coordinate PASRR services, failure to provide necessary equipment for urinary incontinence, medication administration errors, and improper storage of topical medications.
Complaint Details
The complaint investigation substantiated misappropriation of narcotic medications by a nurse for Residents #35 and #26. Adult Protective Services conducted an independent investigation and confirmed abuse, neglect, or exploitation. Additional complaints included inaccurate MDS coding, failure to coordinate PASRR services, failure to provide necessary equipment for urinary incontinence, medication errors, and improper medication storage.
Findings
The facility was found deficient in multiple areas including failure to post survey results in a visible location, misappropriation of narcotic medications by a nurse leading to termination, inaccurate coding of MDS assessments for multiple residents, failure to coordinate care with PASRR for a resident with intellectual disability, failure to provide a bedpan to a resident leading to urinary incontinence episodes, medication error involving incorrect Eliquis dosage administration, and improper storage of topical medications in a resident's room.
Violations (7)
Failure to post location of survey results in the main entrance for easy resident and visitor access.
Misappropriation of narcotic medications (Tramadol) by Registered Nurse #3 from two residents' supplies, substantiated by investigation and resulting in nurse termination.
Failure to accurately code Minimum Data Set (MDS) assessments for 9 residents, affecting cognitive and identifying information.
Failure to coordinate assessments and care planning with PASRR Level II determination and Community Service Board for a resident with intellectual disability.
Failure to provide Resident #8 with a bedpan for use when in bed, contributing to urinary incontinence episodes.
Medication error: Resident #9 was administered Eliquis 5 mg tablet once daily instead of twice daily for 5 1/2 days, resulting in underdosing.
Failure to properly store topical medications in Resident #14's room; medications were kept at bedside instead of secure medication storage.
Report Facts
Residents in survey sample: 35
Tablets of Tramadol taken: 14
Tablets of Tramadol taken: 2
Residents with inaccurate MDS coding: 9
Eliquis tablets under-administered: 11
Eliquis tablets ordered: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Named in medication misappropriation finding involving Tramadol | |
| Social Worker #2 | Interviewed regarding PASRR coordination failure for Resident #17 | |
| LPN #2 | Licensed Practical Nurse | Administered incorrect Eliquis dosage to Resident #9 |
| LPN #1 | Licensed Practical Nurse | Interviewed about Eliquis administration for Resident #9 |
| RN #1 | Registered Nurse | Interviewed regarding Eliquis medication error for Resident #9 |
| Director of Nursing | Involved in investigation and interviews regarding multiple deficiencies |
4 CMS Surveys
CMS Survey — Oct 23, 2025
Oct 23, 2025
CMS Survey — Aug 10, 2017
Aug 10, 2017
CMS Survey — May 16, 2019
May 16, 2019
CMS Survey — Jul 12, 2022
Jul 12, 2022
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