Maimonides Health Center: Safety Hazard Findings - VA
The incident at Maimonides Health Center of Virginia Beach unfolded on a November morning when a certified nursing assistant heard "a noise indicating something had fallen" from the bathroom where the resident had requested privacy to use the toilet.
The charge nurse, identified as LPN #3, found the resident lying on the bathroom floor at 7:40 a.m. The patient was unresponsive with blood coming from her head and no detectable pulse.
Then someone moved her.
Despite the facility's fall policy stating "Do not move resident until assessment has been completed by the nurse," staff used a mechanical Hoyer lift to transfer the unresponsive woman from the bathroom floor to her bed. LPN #3 told federal inspectors she never authorized the move and doesn't know who did it.
"I left the room and when I came back to the room, the Resident was in her bed," LPN #3 stated during interviews. "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 nurse, who had seven years of experience, said she was "really shook up" by the incident and failed to complete any assessment or documentation about the fall. She told inspectors she had "never experienced anything like this before" in her nursing career.
The resident was pronounced dead by a nurse practitioner at 9:30 a.m., nearly two hours after the fall was discovered.
Federal inspectors found the facility violated regulations requiring proper supervision of residents during transfers. The patient, identified as Resident #1 in inspection documents, had been admitted just days earlier and required "supervision or touching assistance" for all transfers, according to her therapy evaluations.
Her physical therapy assessment specified she needed "supervision or touching assistance" for transfers. Her occupational therapy evaluation noted she required "supervision using front wheeled walker" for toilet transfers and "partial/moderate assistance" for toileting hygiene.
The rehab manager explained to inspectors that supervision or touching assistance means "staff should have visual contact with the resident or lay hands on the resident 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."
Instead, the certified nursing assistant left the resident alone in the bathroom after she requested privacy.
The sequence of events began around 7:30 a.m. when the nurse and CNA entered the resident's room to assist with her morning shower. The resident asked to use the toilet first and requested the CNA step out for privacy. Staff provided education about using the call bell and ensured it was within reach.
Minutes later, the CNA heard the fall.
A unit manager's note, entered later that day, documented the timeline: "At 0740, nurse was notified that resident was found lying on the bathroom floor. Nurse promptly responded and assessed the resident. Resident was unresponsive."
The note continued: "Resident had no response to verbal or tactile stimuli. Pulse and respiratory effort were absent. Blood pressure was unappreciated. Pupils were dilated and non-reactive."
The resident had a Do Not Resuscitate order in place, which staff honored. But the decision to move her body using a mechanical lift violated the facility's own safety protocols designed to prevent further injury to fall victims.
Medical records showed the resident was taking Apixaban, a blood-thinning medication prescribed twice daily for atrial fibrillation. Such medications increase bleeding risks from head injuries.
The unit manager notified the resident's daughter at 8:10 a.m. and contacted the attending physician at 8:20 a.m. Family members arrived at the facility at 10 a.m., and the funeral home collected the body at 11:30 a.m.
The unit manager's note described communicating "the resident's death to the family with compassion and sensitivity" and noted that "the family expressed their understanding of the DNR status and shared feeling of loss."
During the investigation, facility leadership presented their fall policy to federal inspectors, though the policy document lacked an effective date. The policy clearly stated the requirement that prompted the violation finding: "Do not move resident until assessment has been completed by the nurse."
LPN #3's failure to complete any assessment or documentation represented a significant breakdown in nursing protocols. Her admission to inspectors that she was too shaken to perform basic nursing duties after discovering the fall raised questions about the facility's crisis response procedures.
The resident had been at Maimonides for only a few days when she died. LPN #3 told inspectors she "did not know her functional abilities," despite the detailed therapy evaluations that specified her transfer requirements.
Federal inspectors conducted multiple interviews over several days, speaking with the charge nurse, rehab manager, and nursing leadership. When given a final opportunity to present additional information, the Director of Nursing and Assistant Director of Nursing "had no further comments and voiced no concerns regarding the above information."
The violation was classified as causing "minimal harm or potential for actual harm" to "few" residents, though the resident in question died shortly after the policy violation occurred.
The incident highlighted gaps in staff training and supervision protocols at the 6401 Auburn Drive facility. The combination of inadequate transfer supervision, policy violations during emergency response, and documentation failures created a cascade of care breakdowns during the resident's final hours.
Nobody answered who moved the dying woman from the bathroom floor to her bed, or why they violated facility policy to do so.
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 charge nurse, identified as LPN #3, found the resident lying on the bathroom floor at 7:40 a.m.
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.