Maimonides Health Center: Notification Failures - VA
The resident had been at the facility for only a few days when she died on the morning she was scheduled for a shower. Physical and occupational therapy evaluations documented that she needed "supervision or touching assistance" for transfers and "supervision using front wheeled walker" for toilet transfers.
Instead, staff left her alone in the bathroom.
The charge nurse, identified as LPN #3 in the federal inspection report, told investigators she "did not complete an assessment on Resident #1 or document any information in the resident's medical record regarding this fall due to never experiencing anything like this before in her seven year nursing career and being really shook up."
At 7:30 that morning, a nurse and certified nursing assistant went to the woman's room to help her prepare for a shower. The resident asked to use the toilet first and requested privacy. Staff placed the call bell within reach and left her alone in the bathroom.
Ten minutes later, the nursing assistant heard a crash.
The CNA found the woman lying unresponsive on the bathroom floor at 7:40 a.m. The charge nurse arrived and discovered the resident had no pulse, no breathing, and blood coming from her head. Her pupils were dilated and non-reactive.
What happened next violated the facility's fall policy, which explicitly states: "Do not move resident until assessment has been completed by the nurse."
Someone used a Hoyer lift to move the woman from the floor to her bed. The charge nurse told investigators she didn't know who moved the resident and that she "did not tell anyone to move her to the bed."
The woman was pronounced dead at 9:30 a.m.
The facility's rehabilitation manager explained to investigators exactly what "supervision or touching assistance with transfers" means: staff should maintain visual contact with the resident or have physical contact "such as on the elbow, hand, arm, the walker, or even using a gait belt while the resident is transferring on and off the toilet."
None of that happened.
The resident's physical therapy evaluation, completed when she arrived at the facility, documented her baseline transfer ability as requiring "supervision or touching assistance." Her occupational therapy evaluation noted she needed "partial/moderate assistance" for toileting hygiene and "supervision using front wheeled walker" for toilet transfers.
The woman was also taking Apixaban, a blood thinner prescribed twice daily for atrial fibrillation. The medication increases bleeding risk from falls.
A unit manager's note, written hours after the death, described the sequence of events in clinical language that masked the policy violations. The note stated the resident "was educated to use the call bell when in need of assistance" and that the "call bell was in place" before staff left her alone.
But education and call bell placement don't substitute for the required supervision.
The charge nurse's admission that she was "really shook up" and had "never experienced anything like this before" suggests the facility may not have adequately prepared staff for managing residents with documented transfer assistance needs.
The woman had a Do Not Resuscitate order, which staff honored when they found her without vital signs. Her daughter was notified at 8:10 a.m., and the attending physician was called ten minutes later.
The family arrived at the facility at 10 a.m. and "expressed their understanding of the DNR status and shared feeling of loss," according to the unit manager's note. The woman's body was transported by funeral home at 11:30 a.m.
Federal investigators conducted interviews on the day of the incident. The rehabilitation manager confirmed the resident's documented need for supervision during transfers. The charge nurse described her shock at the situation and admitted to not following proper assessment and documentation protocols after the fall.
During a final interview with the Director of Nursing and Assistant Director of Nursing, facility leadership was offered an opportunity to provide additional information about the incident. They had no further comments.
The inspection report notes the facility's fall policy was provided to investigators without an effective date, raising questions about when staff were trained on the requirements and whether the policy was properly implemented.
The violation was classified as causing "minimal harm or potential for actual harm" affecting "few" residents, despite resulting in a death. This classification reflects federal inspection standards that focus on systemic facility practices rather than individual incident outcomes.
The case highlights a fundamental breakdown in nursing home safety protocols. A resident with documented transfer limitations was left unsupervised during a high-risk activity, directly contradicting her care plan and facility policy.
The charge nurse's seven years of experience did not prevent her from abandoning basic safety requirements when the resident requested privacy. Her failure to complete any assessment or documentation after finding the resident suggests a concerning lack of preparation for emergency situations.
The woman's death occurred during what should have been a routine morning care activity. Instead, it became a fatal example of how quickly nursing home safety failures can turn deadly when staff ignore established protocols designed to protect vulnerable residents.
Her family's understanding of the DNR order provided some comfort in their loss, but it cannot address the fundamental question of whether this death was preventable through proper supervision and adherence to facility policies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maimonides Health Center of Virginia Beach from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MAIMONIDES HEALTH CENTER OF VIRGINIA BEACH in VIRGINIA BEACH, VA was cited for violations during a health inspection on November 17, 2025.
The resident had been at the facility for only a few days when she died on the morning she was scheduled for a shower.
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.