Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kempsville Health & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral disturbances became combative during care with a CNA, resulting in a skin tear to the resident’s finger and a bruise under the eye. The resident later stated to an RN that the CNA had punched her. The RN reported the incident and allegation to an LPN, who said the DON would be notified but did not contact the DON that night. The DON only learned of the allegation the next morning, and the SSA was not notified until later that day, contrary to facility policy requiring immediate reporting and notification within two hours for abuse allegations.
A resident with severe cognitive impairment and behavioral disturbances became combative during care with a CNA and subsequently had a skin tear on a finger and a contusion with swelling under one eye. The resident later reported to nursing staff that the CNA had hit or punched her, while the CNA stated the skin tear occurred when the resident grabbed her arm and she pulled away, and denied recalling any contact with the resident’s face. Nursing staff documented the facial bruising and swelling, and another nurse noted the CNA was unsure how the facial injury occurred. An internal document suggested the resident hit herself but also acknowledged the resident’s report of being punched. The facility’s investigation did not document whether any facial bruising existed before the incident, did not identify or analyze possible causes of the cheek contusion, and staff interviews did not specifically address the facial injury, resulting in no determination of the probable source of this injury of unknown origin as required by facility policy.
The facility failed to develop and provide resident-specific baseline care plans within 48 hours of admission for multiple newly admitted residents. Instead, staff used generic baseline care plan language that did not identify key conditions such as fractures, post-op wounds, indwelling catheters, wound vacs, IV antibiotics, psychotropic medications, soft collar requirements, or pressure injuries, even though these needs were documented elsewhere in the record. Baseline care plan checklists were often completed after their due dates, and comprehensive care plans addressing these specific needs were delayed by days to weeks. Interviews with an LPN, SSD, MDS coordinator, DON, and DOR confirmed that the baseline care plan process was non–resident-specific, frequently delayed (especially after Friday admissions), and that detailed care needs were typically not reviewed with a resident or representative until a therapy-focused "Path" meeting held several days after admission.
Medication Error Rate Exceeded 5% During Insulin Administration: A medication pass observation found 2 insulin administration errors out of 27 opportunities, resulting in a 7.41% medication error rate. An LPN gave Lantus and Novolog insulin via pen injections and withdrew the pen immediately or after only one second, despite stating she was unaware of the manufacturer’s IFU requiring the needle to remain in the skin for at least 6 seconds to ensure the full dose is given. The DON stated staff were expected to follow the manufacturer’s IFU.
Insulin pens for two residents were found without the date they were opened. An LPN observed during med pass had a Lantus pen and a Novolog pen marked as good for 28 days, but neither had an open date documented at first. The LPN stated she did not know the open date for one pen and assumed the other resident’s admission date was the open date, then added a date to that pen. Staff and facility policy indicated opened meds should be labeled with the date opened and, when applicable, the last date of use.
Failure to Perform Hand Hygiene and Clean Insulin Pen Hubs During Medication Administration: An LPN failed to perform hand hygiene before donning gloves, after glove removal, between resident rooms, and before returning to the med cart while administering meds to two residents, one of whom was on contact precautions for MRSA. The LPN also pierced insulin pen septums without cleaning the pen hub and confirmed the missed hand hygiene and pen cleaning during interview.
Failure to Timely Report Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of staff-to-resident abuse to the State Survey Agency (SSA) in accordance with federal and facility policy requirements. A resident with dementia with behavioral disturbances, restlessness and agitation, bipolar disorder, and a BIMS score of 3/15 indicating severe cognitive impairment, was involved in a combative episode with a CNA during care at approximately 10:00 PM. During this episode, the resident became physically and verbally aggressive, and subsequently sustained a skin tear to the right fourth finger and a bruise under the right eye/cheekbone area. The CNA reported the combative episode and resulting injury to an RN, stating that the resident had grabbed the CNA’s wrist and that the skin tear occurred when the CNA pulled her hand back. The resident told the RN that the CNA had punched her, and the RN notified an LPN of both the incident and the abuse allegation at approximately 10:15 PM. The LPN told the RN that the DON would be notified, but the LPN did not contact the DON that night. The DON did not become aware of the incident and allegation until 7:00 AM the following morning. The facility did not notify the SSA of the staff-to-resident abuse allegation until 5:39 PM that day, exceeding the facility’s policy requirement that all allegations of abuse be reported immediately to the Administrator, DON, and SSA, and that allegations of abuse be reported to the Department of Health immediately, but not later than two hours after the allegation is made. This delay in internal notification and external reporting constituted the deficiency identified by surveyors.
Failure to Thoroughly Investigate Facial Injury Associated With Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate a potential injury of unknown origin related to an allegation of abuse for one resident. The resident had dementia with behavioral disturbances, restlessness, agitation, and bipolar disorder, and was severely cognitively impaired with a BIMS score of 3/15. According to the facility-reported incident, the resident became combative and physically and verbally aggressive during care with a CNA at approximately 10:00 PM, during which the resident sustained a skin tear to the right fourth finger and a contusion to the right cheek. The next morning, the resident told the DON that the CNA had grabbed her hand and hit her face, and when the RN assessed the resident after the incident, the resident stated that the CNA had punched her. The RN documented bruising and mild swelling under the right eye at the bony area and noted that the CNA stated she could have hit the resident’s face while the resident was swinging. The facility’s investigation file contained statements from the CNA describing the resident grabbing her arm and swinging, and the CNA pulling back, causing the skin tear from the CNA’s watch, but the CNA denied remembering any contact with the resident’s face. Another nurse documented observing a swollen and discolored right eye and that the CNA did not know how the facial bruising occurred or whether the resident’s own hand hit her face. An undated abatement document stated the resident became combative, sustained a skin tear, and hit herself, causing swelling to the eye, while also noting that the resident had reported being punched in the face. There was no documentation in the investigation file or EMR ruling out or mentioning any pre-existing facial bruising before the incident or exploring possible causes for the cheek contusion. Although all staff on the unit were interviewed, they were not specifically asked about the cheek contusion, and the Administrator and DON later acknowledged they could not determine the exact cause of the facial injury and that the reenactment focused on the skin tear rather than the cheek contusion, contrary to facility policy requiring a determination of the probable source for injuries of unknown origin.
Failure to Develop and Provide Resident-Specific Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and provide person-centered baseline care plans within 48 hours of admission for multiple newly admitted residents, as required by facility policy. For each of five sampled residents, the baseline care plan section in the admission Observation note contained only generic statements such as receiving medications as ordered, skilled care, pain medications as ordered, skin care to prevent breakdown, dietary needs as ordered, and assistance with activities of daily living as necessary. These baseline care plans did not include resident-specific conditions or treatments that were documented elsewhere in the medical record. The facility’s own policy stated that an interim baseline care plan would be developed within 48 hours of admission to ensure resident needs were met until the comprehensive care plan was completed. For one resident admitted with a displaced fracture of the left femur, muscle wasting, type 2 diabetes, cerebral infarction, and protein calorie malnutrition, the admission notes documented an indwelling urinary catheter and two post-operative surgical wounds to the left hip. However, the baseline care plan did not identify the catheter or the surgical wounds, and the baseline care plan checklist was not completed until several days after it was due. The comprehensive care plan did not address the catheter until more than two weeks after admission and did not address skin integrity until nearly a month after admission. Another resident admitted with a non-traumatic acute subdural hemorrhage, nondisplaced fracture of the right humerus, dysphagia, diabetes with hyperglycemia, protein calorie malnutrition, and dementia had a neurosurgery recommendation for a soft collar at all times following a fall with head injury. The baseline care plan did not identify the fracture or the need for the soft collar, and the baseline care plan checklist was completed after its due date. The resident’s fall and humerus fracture were not included in care planning until several days after admission, and the resident reported not recalling any staff discussing their care or keeping them informed about their care needs. Another resident admitted with a displaced transverse fracture of the right patella, protein calorie malnutrition, PTSD, anxiety, major depressive disorder, and acquired absence of the right upper limb had a surgical incision to the right knee with sutures, slough tissue, and a wound vac, as well as an IV antibiotic order. The baseline care plan did not identify the surgical wound, wound vac, or IV antibiotic, and the checklist was completed late. The comprehensive care plan did not include the antibiotic or wound vac until more than a week after admission. A further resident with a brain neoplasm, protein calorie malnutrition, hemiplegia, and bipolar disorder had antipsychotic, hypnotic, and antidepressant medications ordered upon admission, but these were not specified in the baseline care plan, and the checklist was completed after its due date. The comprehensive care plan did not address these psychotropic medications until nearly two weeks after admission, and the resident stated they were not aware of their plan of care and that no one had reviewed specific aspects of their care or discharge plan with them. A fifth resident admitted with acute kidney failure, protein calorie malnutrition, sepsis, and spinal stenosis had wounds to the sacrum and both buttocks and was receiving antidepressant medication. The baseline care plan again contained only general statements and referenced skin issues with a direction to see orders/observations that were not attached to the document provided to the resident. The baseline care plan checklist was completed after its due date, and the comprehensive care plan did not include the antidepressant use or pressure wounds until several days after admission. Interviews with facility staff, including the SSD, DOR, LPN, MDS coordinator, and DON, confirmed that the baseline care plan was treated as a general, non–resident-specific document attached to the initial nursing observation, that completion often occurred beyond 48 hours (especially for Friday admissions), and that specific care needs were typically discussed later at a “Path” meeting held three to five days after admission. Staff also confirmed that the developed baseline care plan was not specific to resident care needs and was not provided to residents or representatives in a timely manner.
Medication Error Rate Exceeded 5% During Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent. During observation of a medication pass on the 400 unit, 2 medication administration errors were identified out of 27 opportunities, resulting in a 7.41% medication error rate. One LPN administered 48 units of Lantus insulin glargine into R110's abdomen and withdrew the insulin pen immediately. During an interview moments later, the LPN stated she was unaware of the manufacturer's instructions for use and did not know how long the pen should remain in the patient's body after the injection before withdrawal. Later during the same observation, the same LPN injected one unit of Novolog insulin aspart into R69's abdomen and retracted the insulin pen after one second. When interviewed, the LPN stated she had counted one to five quickly before withdrawing the injection and again stated she was unaware of how many seconds the manufacturer recommends holding the pen in place to ensure the full dose is given. Review of the insulin pen instructions for use stated to keep the needle in the skin for at least 6 seconds and keep the push-button pressed all the way in until the needle has been pulled out from the skin. The LPN and the DON both stated it was their expectation that staff follow the manufacturer's instructions for medication injections.
Insulin Pens Not Labeled With Open Dates
Penalty
Summary
The facility failed to ensure that two residents’ insulin pens were labeled with the date they were opened. During medication administration, an LPN withdrew a Lantus insulin pen for one resident and the pen had a bright pink label indicating it was good for 28 days, but the open date was not written on it. When asked, the LPN stated she did not know when it was first opened and confirmed the opened date was not documented on the pen. A second insulin pen, Novolog Aspart for another resident, was also observed during medication administration with a 28-day label but no open date. The LPN acknowledged the missing open date and stated the resident’s admission date must be the open date, then marked the pen with an open date. Staff interviews reflected that insulin pens should be marked with the date they are first opened and the last date of use, and the facility policy stated that once a medication package is opened, staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened.
Failure to Perform Hand Hygiene and Clean Insulin Pen Hubs During Medication Administration
Penalty
Summary
The facility failed to follow appropriate infection prevention practices for two residents during medication administration. During observation on 02/26/25, an LPN pierced the rubber septum of an insulin syringe without first cleaning the pen hub, donned a gown and gloves without performing hand hygiene, and entered one resident’s room to administer medications while the resident was on contact precautions for MRSA. After giving the medication, the LPN removed and discarded the gown and gloves, exited the room, and did not perform hand hygiene before returning to the medication cart, where she reached into her pocket for cart keys, touched the computer keyboard and mouse, and began preparing medications for the next resident. The same LPN then retrieved medications for a second resident, donned gloves without first performing hand hygiene, and entered the resident’s room to use a glucometer for a blood sugar check. After an initial unsuccessful attempt, she removed her gloves and exited without hand hygiene, then later returned to recheck the blood sugar, again removing gloves and returning to the medication cart without hand hygiene. She also applied a needle to an insulin pen without cleaning the hub of the pen before administering insulin to the second resident. During interviews, the LPN confirmed she had not performed hand hygiene before donning gloves, between glove changes, before and after entering residents’ rooms, or between residents, and acknowledged she did not scrub the insulin pens before use.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Virginia Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maimonides Health Center Of Virginia Beach | 1.8 mi | ★★★★★ | 5 | 0 |
| Waterside Health & Rehab Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Our Lady Of Perpetual Help | 2.7 mi | ★★★★★ | 0 | 0 |
| Autumn Care Of Norfolk | 3.9 mi | ★★★★★ | 0 | 0 |
| Cypress Pointe Rehabilitation And Nursing | 4.2 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.