Nans Pointe Rehabilitation and Nursing

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure a signed bed hold were included in the transfer to the hospital for three of four residents (Resident (R) 44, R12, and R73) reviewed for hospitalization out of 24 sample residents. This failure had the potential of not relaying pertinent medical and demographic information to the receiving hospital.

Inspectors wroteBased on observations, record review, interviews, and policy review, the staff failed to wash or sanitize the hands of the residents before a meal and failed to wash or sanitize their own hands while serving the residents their meals for one of four survey days. These failures had the potential to increase the prevalence and spread of foodborne illness and infection for residents served by staff we well as the facility failed to process and store laundry and environmental cleaning items in a safe and sanitary manner to prevent the development and transmission of communicable diseases and infections. Specifically, the facility stored clean resident care and housekeeping items, including bolster pads, used for resident positioning, microfiber cloths, microfiber cleaning pads, dust mops, and clean mop heads, within an area designated for the processing of soiled laundry. [...]

Inspectors wroteBased on record review, interviews, and review of the facility policy, facility failed to provide incontinence care in a timely manner for one of one resident (Resident (R) 129) reviewed for activities of daily living (ADLs) out of a total sample of 24 residents. This failure to provide timely incontinence care places residents at increased risk of urinary tract infections and skin breakdown.

Inspectors wroteBased on observation and interview, the facility failed to have adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. Specifically, the call light system did not function in two of 24 resident (Resident (R) 82 and R129) and the facility did not provide residents in these rooms an adequate alternate means to communicate with nursing staff.

Inspectors wroteBased on observation, staff interviews, and facility document review, the facility staff failed to maintain the fire alarm system in fully operational condition to ensure a safe and accident-free environment to protect the residents, visitors and staff on three of three units, resulting in the identification of immediate jeopardy facility-wide. This resulted in substandard quality of care. Once the IJ (Immediate Jeopardy) was removed, the scope and severity were lowered to level two, widespread.

Inspectors wroteBased on staff interviews and review of facility documents, the facility staff failed to provide leadership and oversight to ensure effective systems were in place to assure the safety of the residents in the area of safety and hazardous free environment and quality assurance and performance improvement activities for three of three units.

Inspectors wroteBased on staff interviews and review of facility documents, the facility's governing body failed to ensure facility policies were implemented regarding management and operation of the facility to ensure effective leadership and systems were in place to ensure the safety of residents, staff and visitors in safety and hazardous free environment for three of three units.

Inspectors wroteBased on staff interviews and review of facility documents, the facility staff failed to adequately identify, keep systems functioning properly, follow facility Fire Watch procedure and implement necessary action plans to assure the safety of all residents, staff and visitors using the Quality Assurance and Performance Improvement (QAPI) committee to identify deficiencies in the area of safety and hazardous free environment for three of three units.

Inspectors wroteBased on observations, staff interview, and during the course of a complaint investigation, the facility staff failed to post the most recent survey results in a place readily accessible to residents, family members, and legal representatives of residents. During an observation on 10/21/25 at 11:15 am., a sign was observed in the facility lobby that read: A copy of the most recent Virginia Department of Health inspection report is available upon request. On 10/22/25 during the course of the survey on this day, no posting of survey results were observed, but the above information was listed. On 10/23/25 at approximately 10:30 am., a brief encounter was made by the administrator near the lobby concerning the survey results book. The administrator said that the book was located in a drawer by the receptionist. [...]

Inspectors wroteBased on observations, staff interviews, and clinical record review, the facility staff failed to administer the ordered antibiotic to 1 of 4 residents in the survey sample (Resident #2).

Inspectors wroteBased on observations, staff interviews, and clinical record review, the facility staff failed to promptly notify the physician and/or practitioner of abnormal lab results for 1 of 4 residents in the survey sample (Resident #2).

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to provide a specialized therapy evaluation resulting in delayed treatment in services which placed the resident in higher risk for decline for 1 of 4 residents (Resident #3), in the survey sample. Resident #3 was originally admitted to the facility 8/24/25 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Cerebral Infarction Due to Unspecified Occlusion or Stenosis. Hemiplegia and Hemiparesis Following Cerebral Infarction. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/29/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. [...]

Inspectors wroteBased on observations, staff interviews, and clinical record review, the facility staff failed to maintain an infection prevention and control program designed to limit opportunities for infection transmission.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to provide pain management to include scheduled narcotic analgesics (Hydromorphone HCl 2 milligrams (mg) and Lyrica 25 mg) which resulted in frequent unnecessary and often excruciating pain, constituting harm for 1 of 47 residents (Resident #267), in the survey sample

Inspectors wroteBased on observations and staff interviews, the facility staff failed to provide food that was prepared by methods that conserved the nutritive flavor and appearance.

Inspectors wroteBased on observations and staff interview, the facility staff failed to store and served food under sanitary conditions.

Inspectors wroteBased on observation and staff interview the facility staff failed to maintain outside refuse area free of debris and trash.

Inspectors wroteBased on observation, and staff interviews, and review of facility documents, the facility staff failed to ensure the facility's floors including resident rooms and common area were kept clean sanitary and homelike.

Inspectors wroteBased resident and staff interviews, facility document review, and clinical record review, the facility staff failed to follow professional standards of nursing practices for 3 out of 47 residents (Resident #68, #22 and #84) in the survey sample.

Inspectors wroteBased on observation, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure a resident wasn't subjected to significant medication errors (omission of critical medications) for 2 of 47 residents (Resident #267 and #319), in the survey sample.

Inspectors wroteBased on record review, staff interview and a review of the facility's contracts, it was determined that the facility staff failed to obtain a dialysis contract that would describe the care and services provided by the dialysis center for one resident (Resident #7) in the survey sample of 47 residents.

Inspectors wroteBased on observation and staff interviews the facility staff failed to meet on a quarterly basis and as needed to identify issues with respect to which quality assessment and assurance activities are necessary. maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to administer the pneumococcal immunization to 3 of 5 residents (Resident #5, 7 and 68) reviewed for the pneumococcal immunization protocol.

Inspectors wroteBased on staff interviews and review of facility documents, the facility staff failed to reduce the risk of COVID-19 transmission from unvaccinated staff by testing staff at least weekly for exempted staff regardless of whether the facility is located in a county with low to moderate community transmission

Inspectors wroteBased on observation, staff interviews, and review of facility documents, the facility staff failed to maintain cleaning equipment in good operational condition to ensure the necessary equipment was available to keep the facility clean, sanitary and homelike.

Inspectors wroteBased on observations and staff interview the facility staff failed to maintain an effective pest control program.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, a review of facility documents and during a complaint investigation, the facility's staff failed to notify family of significant weight loss for 1 of 47 residents (Resident #318), in the survey sample. The findings Included: The POS (Physician Order Summary) for May 2021 reads: Weigh Daily every day shift for Heart Failure Monitoring ALERT MD FOR WT GAIN OF 3LB IN ONE DAY, 5LB IN ONE WEEK, INCREASED EDEMA, SOB. Order date: 3/04/21. Start Date: 3/05/21. House Supplement in the morning 237 ml QD Order Date: 04/09/2022. Start Date: 04/10/2022. The Medication Administration Record (MAR) for May 2022 read: Furosemide Tablet 40 MG Give 1 tablet by mouth two times a day for CHF -Start Date 04/06/2021 1700 -D/C Date 05/23/2022 1204. All doses were administered. [...]

Inspectors wroteBased on a closed record review, staff interview and a complaint investigation, the facility staff failed to provide one resident (Resident #317 ) with an admissions package including admissions policies, transfer/discharge agreement and financial agreement in the survey sample of 47 residents.

Inspectors wroteBased on clinical record review, staff interview and facility documentation, the facility staff failed to ensure that 1 of 47 residents (Resident #86) in the survey sample received a complete and accurate assessment Minimum Data Set (MDS).

Inspectors wroteBased on record review and staff interview, the facility staff failed to conduct a level I PASARR for one Resident (Resident #30) in the survey sample of 47 residents.

Inspectors wroteBased on observation, staff interviews and clinical record review the facility staff failed to ensure 1 of 47 residents (Resident #3) in the survey sample who were unable to carry out activities of daily living receives the necessary services to maintain fingernail care.

Inspectors wroteBased on observation, resident interview, staff interviews, clinical record review, facility documentation review, the facility staff failed to provide 1 of 47 residents (Resident #323) in the survey sample with respiratory care in accordance with professional standards of practice.

Inspectors wroteBased on information obtained during the Sufficient and Competent Nurse Staffing task, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week which could potentially affect all residents. The facility staff failed to staff an RN for at least 8 consecutive hours for 7 days

Inspectors wroteBased on observation and staff interviews the facility staff failed to present its QAPI plan to the State Survey Agency and to ensure Good faith attempts by the committee to identify and correct quality deficiencies.

Inspectors wroteBased on information obtain during the Infection Control task, staff interview, and facility documentation review, the facility staff failed to ensure 1 of 47 residents (Resident #268), didn't receive antibiotics therapy when clinical guidelines for prescribing an antibiotics was not met. The facility staff administered Macrobid 100 milligrams (mg) and Cipro 250 mg (antibiotic) to Resident #68, for a bacteria resistant to the drug.

Inspectors wroteBased on staff interviews the facility staff failed to have a designated Infection Preventionist who had completed a specialized training in infection prevention and control oversee the COVID-19 infection program.

Inspectors wroteBased on staff interviews clinical record review, and review of facility documents, the facility staff failed to inform residents, their representatives, and families of those residing in the facility by 5 p.m., the next calendar day or at least weekly following the occurrence of a single confirmed infection of COVID-19.

Inspectors wroteBased on staff interviews and clinical record reviews the facility staff failed to issue written Bed Hold Notices to 3 Residents and/or Resident Representatives (Resident #17, Resident #121, Resident #106) out of 56 residents in the survey sample, when discharged to the hospital. 1. Resident #17 was discharged to the hospital on [DATE] and the facility staff failed to issue the Resident and/or Resident Representative a written Bed Hold Notice. 2. For Resident #121, the facility staff failed to issue a written Bed Hold Notice to the Resident and/or Resident Representative when discharged to the hospital on [DATE]. 3. The facility staff failed to ensure Resident #106 or Resident Representative (RR), who resided on [NAME] Hall, was issued a written notice of the bed hold reserve policy upon transfer to the local hospital on 2/12/19 and on 3/14/19.

Inspectors wroteBased on observation, staff interview and facility record review, it was determined that facility staff failed to dispose of trash in a sanitary manner for one of one trash compactor and one of one recycle compactor. Facility staff failed to ensure one of one trash compactor and one of one recycle compactor were free from surrounding debris.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and review of the facility's policy the facility staff failed to create an environment to accommodate the needs for 1 of 56 residents (Resident #50), in the survey sample. The facility's staff failed to ensure a call bell system was in place that Resident #50 was capable of using to contact the staff.

Inspectors wroteBased on staff interviews and clinical record reviews the facility staff failed to send care plan summary goals for 4 residents (Resident #17, Resident #121, Resident #111, Resident #106 ) out of 56 residents in the survey sample when discharged to the hospital. 1. The facility staff failed to send Resident # 17's care plan summary goals when discharged to the hospital. 2. The facility staff failed to send care plan summary goals for Resident #121 when discharged to the hospital. 3. The facility staff failed to ensure that Resident #111's Plan of Care Summary to include their care plan goals was sent upon transfer/discharge to the hospital on [DATE]. 4. [...]

Inspectors wroteBased on clinical record review, staff interviews and facility documentation review, the facility staff failed to issue a Preadmission Screening and Resident Review (PASRR) for 1 out of 56 residents (Resident #88) in the survey sample. Resident #88 did not have the required Level I PASRR to assess for service that might be necessary based on diagnosis of a mental disorder.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to develop the comprehensive care plan for two of 56 residents in the survey sample, Resident #44 and #50. 1. For Resident #44, facility staff failed to develop a nutritional care plan to her comprehensive care plan dated 12/27/17. 2. The facility staff failed to develop a care plan to address Resident #50's inability to utilize a regular call light due to decreased range of motion of bilateral hands related to quadriplegia and traumatic brain injury.

Inspectors wroteBased on resident interview, staff interview and facility document review, it was determined that facility staff failed to follow professional standards of practice for one of 56 residents in the surveys sample, Resident #7. For Resident #7, facility staff failed to obtain daily weights per physician's order and the comprehensive care plan.

Inspectors wroteBased on observation, staff interview, resident interview, clinical record review, it was determined that facility staff failed to provide respiratory treatment and services for one of 56 residents in the survey sample, Resident #13. For Resident #13 facility staff failed to administer oxygen per physician's order and comprehensive care plan.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to ensure timely physician visits for one of 56 residents in the survey sample, Resident #44. For Resident #44, facility staff failed to ensure physician visits between the dates of: 5/25/18 through 9/19/18 (over 4 months) and 9/19/18 through 3/23/19 (6 months).

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure Registered Nurse (RN) coverage for 8 hours, 7 days a week. The facility staff failed to ensure RN coverage for 8 hours on three days 11/10/18, 12/09/18 and 01/20/19.

Inspectors wroteBased on staff interview, clinical record review, and review of the facility's Infection Control policy, the facility staff failed to have an Infection Control and Prevention program which monitored all antibiotics administered by the facility staff. The facility's staff failed to have an antibiotic stewardship program which monitored newly and readmitted residents who were prescribed antibiotics in the hospital, to ensure indication of use was validated and the resident was prescribed an appropriate antibiotic.

Inspectors wroteBased on clinical record review, facility documents, staff interviews and review of the facility's policy, the facility staff failed to accurately code Minimum Data Set (MDS) assessments for 9 of 35 residents, (Resident #17, and #27 through #34) in the survey sample. 1. The facility staff failed to accurately code Resident #17's Annual MDS assessment at A1500 and A1510. 2. The facility staff failed to accurately code Resident #27's Initial admission MDS assessment at A0600A and A0600B. 3. The facility staff failed to accurately code Resident #28's Initial admission MDS assessment at A0600A and A0600B. 4. The facility staff failed to accurately code Resident #29's Initial admission MDS assessment at A0800. 5. The facility staff failed to accurately code Resident #30's Initial admission MDS assessment at A0500 and A0600A. 6. [...]

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure 1 of 35 residents in the survey sample, Resident #9, was free of significant medication error . The facility staff failed to administer the correct dosage of Eliquis (1) tablet for Resident #9. Eliquis tablet 5 mg (milligrams) two times a day was administered by the nurses for 5 1/2 days instead of Eliquis 10 mg two times a day, as ordered by the physician.

Inspectors wroteBased on staff interview, family interview, clinical record review, facility document review and during the course of a complaint investigation the facility staff failed to ensure 2 of 35 residents in the survey sample were free from misappropriation of personnel property, Resident #35 and #26. 1. Registered Nurse #3 deliberately took an estimated 14 tablets of the medication Tramadol (1) from Resident #35's medication supply, without administering the medications. 2. Registered Nurse #3 deliberately took two tablets of the medication Tramadol from Resident #26's medication supply, without administering the medication. A Facility Reported Incident (FRI) sent to the State Survey Agency on 4/12/17 reported that an investigation of an allegation of misappropriation of resident's narcotic medication was underway for both Resident #35 and #26. [...]

Inspectors wroteBased on staff interview, clinical record review, and review of the facility's policy the facility staff failed to ensure that an individual with intellectual disability, care and services incorporated the recommendations from the PASRR level II determination and to ensure further Community Service Board services were incorporated into the resident's assessments and care plan for 1 of 35 residents (Resident #17), in the survey sample.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and review of the facility's policy the facility staff failed to ensure 1 of 35 resident (Resident #8) in the survey sample received necessary equipment to aid in prevention of urinary incontinence episodes. The facility staff failed to provide Resident #8 with a bedpan for use when in bed.

Inspectors wroteBased on observation, resident interview, clinical record review and facility document review the facility staff failed to ensure topical (external) medications were properly stored for 1 of 35 residents in the survey sample, Resident #14. A container of ammonium lactate 1% medication cream and a bottle of Triamcinolone 1% medication cream were observed stored inside Resident #14's room.

Inspectors wroteBased on observations the facility staff failed to post location of survey results in the main entrance so visitors entering the facility through that entrance would have knowledge of past survey location.