Nans Pointe Rehab: Infection Control Failure - VA
The resident, identified in inspection records only as Resident #2, was admitted to the facility with an infected diabetic ulcer on the right foot. By mid-October, the wound had worsened enough that a nurse practitioner ordered a lab specimen on October 15. The results came back showing three organisms growing in the wound: Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis. A Contact Precautions sign was posted above the room's door.
What was not posted was an Enhanced Barrier Precautions sign for the roommate.
That distinction matters. The roommate had a PEG tube, a feeding device inserted directly into the stomach, which places residents in a category of heightened vulnerability to acquiring or spreading multidrug-resistant organisms. Enhanced Barrier Precautions, or EBP, require staff to wear gowns and gloves during high-contact care with residents who have indwelling medical devices, open wounds, or known infections, regardless of whether those residents have already tested positive for a resistant organism. The signage alerts every staff member who enters the room.
None of it was there.
When inspectors interviewed the unit manager on October 22, she said at first that the two residents were cohorted in accordance with CDC recommendations. She offered no explanation for why the roommate had no EBP signage. Less than two hours later, the unit manager's account changed. She said she had spoken with the facility's infection preventionist after the interview, and the infection preventionist told her the two residents should not have been kept together at all.
"She had made a mistake," the unit manager acknowledged. Resident #2 should have been isolated. The roommate was moved to another room, and an EBP sign was placed at his door.
The correction happened on October 22. The lab results identifying the three bacterial strains had been sent to the facility before that. The wound care nurse practitioner had flagged the infection on October 15. The inspection tour that first spotted the missing signage took place on October 21.
The inspection report does not say how long the two residents had shared a room after the lab results arrived.
Resident #2 was cognitively intact, scoring 13 out of 15 on a standard mental status assessment. The resident required substantial or complete assistance with nearly every physical task: bathing, dressing, transfers, walking, toileting. That level of dependence means staff were regularly performing exactly the kind of close physical care that EBP protocols are designed to govern.
The roommate's condition beyond the PEG tube is not described in the inspection report. What is described is that he had no protective signage, and that staff had no written alert to put on gowns and gloves before caring for him in a room shared with someone whose wound was actively growing three bacterial strains.
More than half of nursing home residents may be colonized with a multidrug-resistant organism at any given time, according to a 2021 white paper from the Healthcare Infection Control Practices Advisory Committee. That figure is part of the reason EBP protocols were developed specifically for long-term care settings, where residents cannot simply be confined to their rooms and where the same staff move between patients throughout a shift.
The facility's own infection prevention and control policy, last revised in December 2022, states that all staff are responsible for following all policies and procedures related to the program.
On October 23, inspectors presented their findings to the facility's administrator, director of nursing, a corporate consultant, and the president of operations. The inspection report states that they had no comments and voiced no concerns.
The roommate, moved down the hall after days in the wrong room, is not mentioned again in the report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nans Pointe Rehabilitation and Nursing from 2025-10-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
NANS POINTE REHABILITATION AND NURSING in SUFFOLK, VA was cited for violations during a health inspection on October 23, 2025.
The resident, identified in inspection records only as Resident #2, was admitted to the facility with an infected diabetic ulcer on the right foot.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.