Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Maimonides Health Center Of Virginia Beach during CMS and state inspections, most recent first.
Facility staff did not promptly notify responsible parties and medical providers of significant changes in condition for two residents, including rapid weight gain, worsening edema, and severe abdominal pain. These failures led to delayed interventions, with one resident experiencing a fatal outcome after delayed hospital transfer and another developing sepsis from a perforated ulcer. Family members reported difficulty reaching staff and were not informed of their loved ones' deteriorating conditions until late.
Two residents experienced neglect due to staff failing to provide timely care, including delayed notification of physicians and responsible parties, inadequate monitoring and response to worsening symptoms, insufficient provision of fluids and hygiene, and delayed transfer to the hospital. One resident with severe cardiac issues was not properly monitored for weight gain and edema, while another with multiple comorbidities suffered prolonged abdominal pain and was not assessed or transferred promptly, resulting in a diagnosis of septic shock and a perforated ulcer.
A resident with complex medical needs, including nephrostomy tubes and severe heart failure, did not receive adequate bathing or ADL care during a 43-day stay. Despite staff indicating that showers or tub baths are typically provided twice weekly and daily bed baths as needed, the resident received only three bed baths and had two documented refusals, with no other hygiene care documented. Other residents were found to have received appropriate hygiene care.
A resident with significant physical and cognitive impairments, dependent for toileting hygiene and requiring supervision for transfers, was left unattended in the bathroom after requesting privacy. The resident was later found unresponsive on the floor with a head injury and was pronounced deceased. Staff interviews and records confirmed that the required supervision was not provided, and the resident was moved before a full nursing assessment was completed, contrary to facility policy.
A resident with a fluid restriction experienced significant weight gain, edema, and shortness of breath due to staff failing to provide adequate hydration and not notifying the cardiologist as required. Despite daily weight monitoring and clear care plan instructions, the resident rarely received the prescribed fluid amount, and staff and family reported frequent complaints of thirst. The facility physician adjusted medications to manage symptoms, but the underlying deficiency in hydration and monitoring persisted.
A resident with severe cognitive impairment and a history of CHF and DVT experienced persistent cough, new bilateral leg edema, and was not weighed as scheduled. Staff did not promptly recognize or act on these symptoms of heart failure exacerbation, resulting in delayed assessment and intervention.
A resident with severe cognitive impairment and multiple medical conditions developed a sacral pressure ulcer that was not properly addressed in the care plan or consistently documented by staff. Required weekly skin assessments were missed, and the ulcer's progression was not adequately tracked, resulting in a deficiency related to pressure ulcer prevention and management.
Facility staff did not promptly notify the physician and a resident's representative about multiple significant changes in the resident's skin condition, including injuries and new wounds. Despite documentation of these changes and a care plan requiring notification, there was no evidence that the required notifications were made, as confirmed by facility leadership and record review.
Facility staff did not follow abuse and neglect policies when a resident with severe cognitive impairment and total dependence was found with a black and blue area on the chest. Required notifications to the physician and resident representative were not documented, and no investigation into the injury was conducted, despite staff acknowledging that such injuries should be reported and investigated according to facility policy.
A resident with severe cognitive impairment and total dependence was found with a black and blue area on the chest, but staff did not report the injury of unknown origin to the physician, resident representative, or state agencies within required timeframes. Interviews and record reviews confirmed that facility policies for immediate reporting and investigation were not followed, and no documentation of timely notification or investigation was found.
A resident with severe cognitive impairment and total dependence was found with a black and blue bruise on the chest, but staff did not conduct a thorough investigation or document a Facility Reported Incident as required by facility policy. Interviews with staff confirmed that the expected procedures for reporting and investigating such injuries were not followed.
A resident admitted with multiple chronic conditions who primarily spoke Spanish did not have her communication needs addressed in her baseline care plan. Staff relied on her son for translation or used ad hoc methods like phone apps, and the resident was unable to communicate dietary preferences until a Spanish-speaking surveyor intervened. The deficiency was due to the absence of a person-centered, effective communication plan for the resident.
Facility staff did not update person-centered care plans when residents experienced changes in condition, such as new pressure ulcers and skin injuries. For example, a resident with severe cognitive impairment developed a stage two sacral pressure ulcer that was not addressed in the care plan, and another resident with multiple diagnoses had several skin issues that were not reflected in care plan updates. Required interdisciplinary team input was also missing from at least one care plan meeting.
A resident with severe cognitive impairment and multiple health conditions experienced significant weight loss due to staff failing to recognize and address signs of malnutrition, inconsistently consulting the RD as ordered, and not implementing care plan interventions such as regular weight monitoring and timely dietary changes.
A resident with multiple chronic conditions and intact cognition was found with a cup containing about ten pills left at the bedside after refusing to take them when offered by an LPN. The LPN left the medications at the resident's request instead of returning them to the medication cart, contrary to professional standards.
A resident with severe cognitive impairment and multiple diagnoses was started on hospice services without a written contract in place between the facility and the hospice provider. Hospice care documentation, including care plans and orders, was not maintained in the electronic health record, and staff communication with hospice was informal and lacked a structured process.
An LPN failed to perform proper hand hygiene during wound care for a resident with multiple chronic conditions, neglecting to remove gloves and sanitize hands before handling clean supplies. This breach of infection control protocol was observed and acknowledged by the staff member.
A resident's code status was changed to DNR/DNI without authorization, despite their expressed wish to remain a full code. The resident's family discovered the change and requested it be reverted. Interviews revealed inconsistencies in the facility's process for discussing code status, with staff unclear on who is responsible for these discussions.
Two residents in a facility experienced significant medication errors. A post-kidney transplant resident was given Cyclophosphamide instead of Cyclosporine for eight days due to a provider error and miscommunication. Another resident missed three doses of Phenobarbital due to unavailability and delayed pharmacy communication. These errors highlight lapses in medication administration and verification processes.
Failure to Notify Responsible Parties and Providers of Changes in Condition
Penalty
Summary
Facility staff failed to notify residents' representatives and medical providers of significant changes in condition for two residents, resulting in harm. One resident with complex cardiac and renal conditions experienced a rapid and sustained weight gain, worsening edema, and shortness of breath over several days. Despite care plan instructions and hospital discharge orders requiring immediate physician notification for specific weight increases, there was no evidence that the cardiology physician was contacted. The resident's family was not informed of these concerning symptoms until the family member initiated contact, and the resident was ultimately sent to the hospital only after the family insisted, where she later expired. Another resident with multiple chronic conditions, including diabetes, chronic kidney disease, and heart failure, reported severe abdominal pain and vomiting over an extended period. Documentation and interviews revealed that the resident's pain and deteriorating condition were not promptly communicated to the Nurse Practitioner or the resident's Power of Attorney/daughter. The resident continued to experience pain and was not transferred to the hospital until many hours after the initial complaints, with the family only being notified shortly before the transfer. The delay in notification and treatment contributed to the resident's decline, and the hospital later determined the resident became septic due to a perforated ulcer. Interviews with staff and family members confirmed that communication failures occurred, with family members having difficulty reaching staff and not being informed of significant changes in the residents' conditions. Clinical records and care plans indicated that staff did not follow established protocols for timely notification of changes in condition to both medical providers and responsible parties, resulting in delayed interventions and harm to the residents.
Failure to Provide Timely Care and Services Resulting in Resident Neglect
Penalty
Summary
Facility staff failed to protect two residents from neglect by not providing timely care and necessary services. One resident with severe cardiac disease and nephrostomy tubes experienced a significant weight gain, worsening edema, and shortness of breath over a 43-day stay. Despite clear care plan instructions and hospital discharge orders to notify cardiology for specific weight gains, there was no evidence that the cardiology physician was ever contacted. The resident's fluid intake was consistently below the ordered restriction, and documentation showed inadequate provision of fluids and bathing, with only three bed baths recorded and no showers provided. The resident's family was not notified of her worsening condition, and she was not sent to the emergency room until three hours after the order was received, ultimately expiring in the hospital two days later. Another resident with multiple comorbidities, including diabetes, chronic kidney disease, and heart failure, reported severe abdominal pain and vomiting. The resident's complaints began late at night and persisted for over 11 hours before a nurse practitioner was notified. During this period, the resident continued to experience pain, was unable to eat, and required repeated pain assessments and interventions. The facility staff did not notify the resident's responsible party of the change in condition until more than 17 hours after the initial complaint. The resident was eventually transferred to the hospital, where she was diagnosed with septic shock and a perforated ulcer. Staff interviews and clinical record reviews confirmed delays in notification, assessment, and treatment for both residents. The facility failed to provide required goods and services, including timely medical intervention, adequate hydration, hygiene, and communication with family members. These failures resulted in neglect as defined by federal regulations, with harm identified for one resident and significant delays in care for the other.
Failure to Provide Adequate Bathing and ADL Care to Dependent Resident
Penalty
Summary
Facility staff failed to provide adequate bathing and activities of daily living (ADL) care to a dependent resident with significant medical needs, including nephrostomy tubes, chronic heart failure, and an artificial heart valve. The resident was admitted with an order for oxygen and had a severely weakened heart muscle. Review of ADL records showed that the resident received only three bed baths during a 43-day stay, with only two documented refusals for bathing. No other baths or showers were provided during this period, despite the resident's condition requiring frequent hygiene care due to the presence of nephrostomy tubes, which are known to leak and necessitate regular cleaning. Interviews with staff indicated that the standard practice was to provide showers or tub baths twice weekly and daily bed baths as needed. However, this standard was not met for the resident in question. Other residents reviewed during the survey were found to have received adequate hygiene care, and no issues were reported by other residents or family members. The deficiency was communicated to the Director of Nursing and Assistant Director of Nursing, who did not provide additional information.
Failure to Provide Adequate Supervision During Toileting Results in Resident Fall and Death
Penalty
Summary
Facility staff failed to provide adequate supervision to prevent an accident for a resident with significant physical and cognitive impairments. The resident, who had diagnoses including acute kidney failure, chronic obstructive pulmonary disease, unsteadiness on feet, and chronic congestive heart failure, was assessed as dependent for toileting hygiene and required supervision or touching assistance for transfers. Despite these needs, the resident was left unattended in the bathroom during toileting after requesting privacy, with the CNA stepping out and closing the bathroom door but remaining in the room. Shortly after, a noise was heard, and the resident was found on the bathroom floor, unresponsive, with a head injury and blood present. The resident was taking Apixaban for atrial fibrillation, which increases the risk of bleeding. The care plan and therapy evaluations indicated the resident required at least supervision or hands-on assistance for toileting and transfers, and the facility's fall policy required that residents not be moved until a nurse completed an assessment. However, after the fall, the resident was moved from the bathroom floor to the bed using a Hoyer lift by two staff members before a full assessment was completed. The charge nurse did not direct this action and did not perform or document an assessment due to being emotionally affected by the incident. Interviews with facility staff, including the nurse practitioner, LPN, and rehab manager, confirmed that the resident's functional abilities required supervision during toileting and transfers. Documentation and staff statements revealed that the required level of supervision was not provided, and the resident was left alone despite being dependent for toileting hygiene. The lack of adequate supervision and failure to follow established protocols directly contributed to the resident's unwitnessed fall and subsequent death.
Failure to Maintain Adequate Hydration and Monitoring for a Dependent Resident
Penalty
Summary
Facility staff failed to maintain adequate hydration for a resident who was dependent on staff for care. Upon admission, the resident had hospital orders for labs to be drawn in three days, but the facility delayed the first lab draw to eight days after admission and then scheduled subsequent labs at irregular intervals. The resident was placed on a 1500 ml fluid restriction, with daily weights ordered and documented. Despite clear instructions in the hospital discharge summary and care plan to notify the cardiology physician if the resident experienced a significant weight gain or worsening edema, there is no evidence that the cardiologist was ever contacted, even as the resident's weight increased by over 8 pounds, and symptoms of edema and shortness of breath developed. Instead, the facility physician made four medication changes to manage fluid overload symptoms. Review of intake and output records revealed that the resident rarely received the full amount of fluids allowed by the restriction, with only one day where the 1500 ml limit was met. Most days, the resident received significantly less, and there were days with no fluids recorded at all. Staff and family interviews indicated that the resident frequently complained of thirst and sought fluids from others, contradicting staff notes of noncompliance with the fluid restriction. The pattern of inadequate fluid provision, lack of timely physician notification, and insufficient monitoring contributed to the resident's worsening condition during the stay.
Failure to Recognize and Respond to Heart Failure Exacerbation
Penalty
Summary
Facility staff failed to recognize and respond to symptoms indicating an exacerbation of heart failure in a resident with a history of chronic non-occlusive DVT and congestive heart failure with a reduced ejection fraction of 30 percent. The resident, who had severely impaired cognitive abilities, reported a persistent dry cough that had not improved with her usual home remedy, as well as new swelling in her right leg in addition to known left leg edema. Observations confirmed significant pitting edema in both legs, and the resident was found to be wearing non-skid socks that left indentations, with no compression hose available due to improper fit. The resident also reported not being weighed for several days and was unaware of her current weight. Staff interviews and clinical record review revealed that the resident had not been weighed as scheduled, and her symptoms of worsening heart failure, including increased edema and a cough persisting for weeks, were not promptly recognized or addressed. When the resident was finally weighed, a significant weight gain of over three pounds in one day was noted, prompting a change in her treatment plan. The delay in assessment and intervention contributed to the failure to provide appropriate care according to the resident's orders, preferences, and goals.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
Facility staff failed to prevent the development of a pressure ulcer and did not provide appropriate management for an avoidable pressure ulcer in one resident. The resident, who had significant cognitive impairment and multiple medical conditions including chronic non-occlusive DVT and congestive heart failure, was admitted after a hospital stay. Initial assessments indicated intact skin, but a sacral pressure ulcer was identified within eleven days of admission. The care plan noted the resident was at risk for impaired skin integrity but did not address the newly developed sacral ulcer after it was identified. Documentation of the pressure ulcer's progression was incomplete, with missing weekly skin observation tools and lack of detailed information such as measurements, stage, and characteristics for several weeks. Staff interviews confirmed that required weekly skin assessments were not consistently performed or documented. The resident reported ongoing discomfort from the ulcer, and direct observation confirmed the presence of a stage two sacral pressure ulcer. The deficiency was due to the facility's failure to consistently assess, document, and update the care plan to address the resident's pressure ulcer after its development.
Failure to Notify Physician and Resident Representative of Significant Change
Penalty
Summary
Facility staff failed to immediately notify the physician and the resident's representative of significant changes in a resident's condition on multiple occasions. The resident, who had severe cognitive impairment and was totally dependent on staff for activities of daily living, experienced several changes in skin condition, including an area on the chest that was black and blue, skin tears on both wrists, blisters on both feet, and an open area on the left posterior shoulder. Documentation in the clinical record indicated that while some changes were noted and referred to medical staff, there was no evidence that the resident's representative was promptly notified as required by facility policy. Interviews with facility leadership confirmed the lack of documentation regarding immediate notification to the physician and resident's representative for the identified changes in condition. The resident's care plan included interventions to monitor and report changes in skin condition, and the facility's policy required prompt notification of significant changes. However, reviews of the clinical record and care plan revealed that these procedures were not consistently followed, resulting in a failure to communicate important health status changes to the appropriate parties.
Failure to Implement Abuse and Neglect Policy for Injury of Unknown Origin
Penalty
Summary
Facility staff failed to implement the abuse and neglect policy for a resident with severe cognitive impairment and total dependence for activities of daily living, who was found with an injury of unknown origin. The resident, who had multiple diagnoses including dementia, malnutrition, and osteoporosis, was discovered by an RN to have a black and blue area on the chest. Despite this finding, there was no evidence that the required notifications to the physician or resident representative were made, nor was there documentation of an investigation into the injury as required by facility policy. Interviews with facility staff, including the administrator, CNA, LPN, and ADON, revealed a lack of follow-through on the established procedures for reporting and investigating unexplained injuries. Staff confirmed that any new injuries or changes in condition should be immediately reported to the nurse, and that injuries of unknown origin, especially in nonverbal residents, should be reported to the physician and family and investigated for possible abuse or neglect. However, the administrator was unable to provide any investigation records related to the injury, and the ADON could not find documentation of immediate notifications or an incident report in the resident's record. A review of facility policies confirmed that all unexplained injuries, including bruises and injuries of unknown source, must be investigated, documented, and reported to the appropriate parties. The policy also requires modification of the care plan to prevent recurrence. In this case, the facility did not follow its own procedures for reporting, investigating, and documenting the injury of unknown origin, resulting in a failure to protect the resident as required by policy.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
Facility staff failed to ensure the timely reporting of an injury of unknown origin for one resident with severe cognitive impairment and total dependence for activities of daily living. The resident, who had multiple complex diagnoses including dementia, malnutrition, and physical debility, was found by an RN to have a black and blue area on the chest. The nurse documented the finding and intended to notify the nurse practitioner, but there was no evidence that the injury was reported to the physician, resident representative, or appropriate state agencies within the required timeframes. Interviews with facility staff, including the Administrator, CNA, LPN, and ADON, revealed that the facility's policy requires immediate reporting and investigation of unexplained injuries, as well as notification of the physician and resident representative. However, the Administrator confirmed that no Facility Reported Incident (FRI) was submitted for this injury, and the ADON was unable to find documentation of timely notifications or an investigation related to the incident. Staff interviews further confirmed that such injuries, especially in nonverbal residents, should be treated as potential abuse or neglect and reported accordingly. A review of facility policies on unexplained injuries and abuse indicated clear procedures for reporting, investigating, and notifying appropriate parties within specified timeframes. Despite these policies, the required steps were not followed in this case, as there was no documentation of immediate notification or investigation of the injury of unknown origin. The deficiency was confirmed during the survey, and no additional information was provided by the facility at the end of the review.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and total dependence for activities of daily living. The resident, who had multiple diagnoses including dementia, malnutrition, and osteoporosis, was found to have a black and blue bruise on the chest by an RN, who documented the finding and noted intent to notify the nurse practitioner. However, there was no evidence that a comprehensive investigation was initiated or completed regarding the injury. Interviews with facility staff, including the administrator, CNA, LPN, and ADON, confirmed that the facility's policy requires immediate investigation and notification of the physician and resident representative for injuries of unknown origin. Despite these policies, the administrator was unable to provide any documentation of a Facility Reported Incident or investigation related to the injury. The facility's own policy outlines specific steps for investigating alleged abuse or neglect, but these procedures were not followed in this case.
Failure to Address Communication Needs for Spanish-Speaking Resident
Penalty
Summary
Facility staff failed to ensure that the baseline care plan for a newly admitted Spanish-speaking resident addressed her communication needs. The resident, who was admitted with multiple diagnoses including sepsis, type 2 diabetes mellitus, chronic kidney disease, hypertension, peripheral vascular disease, and anemia, had no mention of her language preference or communication requirements in her baseline care plan. Staff interviews and observations revealed that the resident primarily spoke Spanish, and staff members attempted to communicate with her using gestures, limited English, or by relying on her son to translate. The son was not always present, and staff sometimes attempted to use personal translation apps on their phones. During meal service, the resident was unable to understand what was on her tray until a Spanish-speaking surveyor intervened, indicating that her dietary preferences and needs were not being effectively communicated. Staff acknowledged the importance of communication but did not have a consistent or facility-approved method in place at the time of the survey. The lack of a person-centered, effective communication plan was evident in the care provided, as the resident's ability to participate in her care and express her needs was compromised.
Failure to Revise Care Plans After Changes in Resident Condition
Penalty
Summary
Facility staff failed to review and revise person-centered care plans as residents' conditions changed, resulting in deficiencies for two residents. One resident, admitted after an acute hospital stay with diagnoses including chronic non-occlusive DVT and congestive heart failure, was assessed as having severely impaired cognitive abilities. Despite the development of a care plan addressing risk for impaired skin integrity, the plan was not updated to address a newly identified open area on the sacrum, which was later observed and assessed as a stage two sacral pressure ulcer. Another resident with multiple complex diagnoses, including dementia, severe protein calorie malnutrition, and total dependence for activities of daily living, experienced several skin issues such as skin tears, blisters, and open areas. Progress notes documented these changes, but the care plan was not revised to reflect the new injuries or pressure areas. Additionally, there was a lack of documentation showing immediate physician or responsible party notification of these changes in condition. The facility's policy requires that comprehensive care plans be prepared, reviewed, and revised by an interdisciplinary team after each comprehensive and quarterly MDS assessment, and that care plans include measurable objectives and time frames. However, the care plans for both residents were not updated in response to significant changes in their conditions, and required interdisciplinary team input was missing from at least one care plan meeting.
Failure to Ensure Adequate Nutrition and Timely Dietary Intervention
Penalty
Summary
Facility staff failed to ensure adequate nutrition for a resident with severe cognitive impairment and multiple comorbidities, including dementia, severe protein calorie malnutrition, and dysphagia. The resident experienced a significant weight loss of 29 pounds over a period of approximately six weeks. Despite documented evidence of underweight status and ongoing weight loss, staff did not consistently recognize or respond to signs of malnutrition, nor did they consult with the registered dietician for recommendations as ordered by the physician on several occasions. Medical records and provider notes indicated repeated concerns about the resident's low BMI, declining oral intake, and the need for close monitoring and dietary consultation. The registered dietician's evaluation lacked current weight data and did not recommend changes, stating that intake met or exceeded estimated needs, despite evidence to the contrary. The resident's care plan included goals for gradual weight gain and interventions for monitoring and reporting signs of malnutrition, but these were not effectively implemented, as weights were not regularly checked and dietary consults were not consistently obtained. Documentation also revealed confusion regarding the resident's hospice status, which impacted the monitoring of weights and implementation of care plan interventions. The resident was not on hospice for a period when the care plan indicated otherwise, and routine weights were not obtained during this time. Supplements and dietary changes were not initiated in a timely manner, with house shakes only ordered on the day of the resident's death, despite ongoing weight loss and nutritional risk.
Medications Left Unattended at Bedside
Penalty
Summary
Facility staff failed to ensure that medications were administered in accordance with accepted professional standards for one resident. The resident, who had diagnoses including atrial fibrillation, diabetes, and hypertension, was cognitively intact as indicated by a high BIMS score. During an observation, a medication cup containing approximately ten pills of various sizes and colors was found on the resident's bedside table. The resident explained that he could not take the medications when they were brought to him because he had a piece of candy in his mouth and intended to take them after finishing the candy. An interview with the LPN responsible for administering the medications revealed that the nurse left the medications at the bedside at the resident's request, as the resident was described as non-compliant with care and refused to take the medications at the time they were offered. The LPN later retrieved the empty medication cup, indicating the resident had taken the medications. The facility's administration confirmed that the nurse should not have left the medications at the bedside and should have returned them to the medication cart.
Failure to Secure Hospice Contract and Maintain Hospice Records
Penalty
Summary
Facility staff failed to secure a written agreement with a hospice provider prior to the initiation of hospice services for a resident with multiple complex medical conditions, including dementia, severe protein calorie malnutrition, major depressive disorder, and total dependence for activities of daily living. The resident was started on hospice services, but the required contract with the hospice provider was not in place until the first day of the survey. Additionally, hospice care documentation, including care plans, visit notes, and medication and treatment orders, was not maintained in the resident's electronic health record during the period hospice services were provided. The deficiency was identified through interviews, clinical record review, and facility documentation. The administrator and staff were unable to locate the original hospice contract and had to request a new one from the hospice provider. Communication between facility staff and hospice was described as occurring verbally and by telephone, but there was no established process for ensuring hospice records were integrated into the facility's electronic health record.
Failure to Follow Hand Hygiene During Wound Care
Penalty
Summary
Facility staff failed to adhere to proper hand hygiene practices during wound care for one resident. During an observation of sacral pressure ulcer care, an LPN, assisted by a CNA, performed wound cleansing and dressing changes. After cleaning the wound and before handling clean wound care supplies, the LPN did not remove her gloves or wash or sanitize her hands, as required by infection prevention protocols. This lapse was acknowledged by the LPN during an immediate post-procedure interview. The resident involved had a history of atrial fibrillation, diabetes, and hypertension, and was cognitively intact at the time of the incident. The wound care procedure required the use of clean gloves and hand hygiene between handling soiled and clean supplies, but these steps were not followed, as directly observed by surveyors.
Unauthorized Change of Code Status for Resident
Penalty
Summary
The facility staff failed to respect and honor a resident's right to remain a full code, as evidenced by the unauthorized change of code status for a resident who was admitted from the hospital as a full code and expressed wishes to remain so. Despite the resident's clear communication and cognitive ability to make decisions, an order was entered to change the resident to a DNR/DNI without a signed document to support this change. The resident's family member discovered the unauthorized change and requested the order be reverted to the resident's original wishes. Interviews with facility staff revealed inconsistencies in the process of discussing code status with residents. The Licensed Practical Nurse indicated that the social worker typically discusses code status, while the Assistant Director of Nursing stated that the doctor would have this conversation. The Social Service Director mentioned not seeing residents until 72 hours after admission, which may have contributed to the oversight. The facility's policy on resident rights emphasizes participation in care decisions, yet this was not upheld in the case of the resident in question.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #7, who was a post-kidney transplant patient, was mistakenly administered Cyclophosphamide, a chemotherapy drug, instead of the prescribed Cyclosporine, an immunosuppressant necessary to prevent organ rejection. This error occurred over an eight-day period during which the resident received multiple incorrect doses. The error was identified when the transplant clinic contacted the facility to verify the medication, leading to the resident being sent to the hospital for evaluation. The error for Resident #7 was traced back to a provider mistake where Cyclophosphamide was ordered instead of Cyclosporine. The error was compounded by the fact that the correct medication was not listed on the hospital discharge summary, and the facility did not accept medications brought in by the family. Despite the family providing accurate medication information, the facility continued to administer the wrong medication until the transplant center intervened. Resident #6 experienced a significant medication error when the facility failed to administer the ordered anti-seizure medication, Phenobarbital, for three days. This lapse was due to the medication not being available and a delay in communication with the pharmacy. The facility's emergency medication supply did not include Phenobarbital, and the staff did not follow up promptly to ensure the medication was obtained. This oversight left the resident without necessary medication for seizure control, posing a risk of seizures.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Kempsville Health & Rehab Center | 1.8 mi | ★★★★★ | 9 | 0 |
| Waterside Health & Rehab Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Autumn Care Of Norfolk | 3.1 mi | ★★★★★ | 0 | 0 |
| Oak Grove Health & Rehab Center, Llc | 4.1 mi | ★★★★★ | 6 | 0 |
| Lake Taylor Hosp | 4.4 mi | ★★★★★ | 5 | 0 |
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