Maimonides Health Center: Nutrition Deficiency - VA
The incident at Maimonides Health Center of Virginia Beach occurred on a morning when a certified nursing assistant and licensed practical nurse brought the resident to the bathroom for a shower. The woman, identified in inspection records as Resident #1, asked to use the toilet first and requested privacy.
The CNA stepped out. Shortly after, she heard a noise indicating something had fallen.
What happened next violated the facility's own fall policy and contributed to a chain of events that ended with the woman's death 90 minutes later.
The CNA found the resident lying on the bathroom floor at 7:40 AM. The charge nurse, LPN #3, responded and discovered the woman was unresponsive with blood coming from her head. But instead of following protocol, staff used a Hoyer lift to move the resident from the floor to her bed.
"Do not move resident until assessment has been completed by the nurse," the facility's fall policy explicitly states.
LPN #3 later told investigators she never completed an assessment or documented anything about the fall in the resident's medical record. She said she was "really shook up" because she had never experienced anything like this in her seven-year nursing career.
"I left the room and when I came back to the room, the Resident was in her bed," LPN #3 told investigators. "I do not know who used the hoyer lift and moved the resident to the bed. I was the charge nurse and did not tell anyone to move her to the bed."
The resident was pronounced dead at 9:30 AM by a nurse practitioner.
The woman should never have been left alone in the first place. Her physical therapy evaluation, completed just days before her death, clearly documented that she required "supervision or touching assistance" for all transfers. Her occupational therapy evaluation specified she needed "supervision using front wheeled walker" for toilet transfers.
The facility's rehabilitation manager explained what this supervision requirement meant: staff should maintain visual contact with the resident or provide hands-on assistance by touching the resident's elbow, hand, arm, walker, or using a gait belt during transfers on and off the toilet.
Instead, the CNA left the woman completely alone.
The resident had been taking Apixaban, a blood-thinning medication prescribed twice daily for atrial fibrillation. The medication can increase bleeding risks, making proper fall protocols even more critical.
Federal investigators found the facility failed to ensure residents received supervision and assistive devices as prescribed by their care plans. The violation was classified as causing minimal harm or potential for actual harm to a few residents.
LPN #3's account reveals the chaos that followed the fall. She described finding the resident unresponsive with no pulse and blood coming from her head, yet couldn't explain who decided to move the woman or why the fall policy was ignored.
"The Resident was not responding and did not have a pulse. She had blood coming from her head," LPN #3 told investigators. "She had only been here a few days and I did not know her functional abilities."
The unit manager's nursing note, entered late that day, provided additional details about the timeline. At 7:30 AM, staff had gone to assist the resident with her shower. By 7:40 AM, she was found on the bathroom floor. The unit manager was alerted at 8:03 AM, the resident's daughter was informed at 8:10 AM, and the physician was notified at 8:20 AM.
The resident had a do-not-resuscitate order in place, which meant no CPR would be attempted. But the DNR status didn't excuse the facility from following basic safety protocols after a fall.
The woman's daughter came to the facility at 10:00 AM, after her mother had already died. According to the nursing note, she "expressed their understanding of the DNR status and shared feeling of loss" and inquired about funeral arrangements.
The body was picked up by a funeral home at 11:30 AM.
The inspection report reveals a breakdown in multiple systems. The charge nurse failed to conduct a post-fall assessment, failed to document the incident properly, and couldn't explain who moved the resident despite being in charge. Staff violated the facility's own fall policy by moving the woman before completing an assessment.
Most critically, the resident was left unsupervised during a transfer despite clear documentation that she required constant supervision or hands-on assistance.
The rehabilitation manager's interview with investigators underscored how specific the supervision requirements were. The woman needed visual contact or physical guidance for every transfer, whether that meant touching her arm, steadying her walker, or using a gait belt.
"Supervision or touching assistance with transfers means that the staff should have visual contact with the resident or lay hands on the resident," the rehabilitation manager explained.
The facility had no additional comments when investigators offered a final opportunity to present information. The director of nursing and assistant director of nursing "voiced no concerns regarding the above information."
The woman had been at Maimonides Health Center for only a few days when she died. Her care plan was clear, her needs were documented, and the facility's policies were explicit about post-fall procedures.
None of it mattered on the morning she asked for privacy in a bathroom and was left alone to fall.
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 woman, identified in inspection records as Resident #1, asked to use the toilet first and requested privacy.
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.