Nans Pointe Rehabilitation And Nursing

F 0577

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Level of Harm - Minimal harm or potential for actual harm

Based 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. A pre-exit interview was conducted on 10/23/25 at approximately 1:30 pm., the above findings were shared with the Administrator,

The Corporate Consultant and the DON (Director of Nursing) and [NAME] President of Clinical Services.

An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nans Pointe Rehabilitation and Nursing

200 West Constance Road Suffolk, VA 23434

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).The findings included: Resident #2 was initially admitted to the facility on [DATE REDACTED]. The resident's current diagnoses included an infected diabetic ulcer of the right foot. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/17/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated that Resident #2's cognitive abilities for daily decision-making were intact. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with showers/bathes, and upper body dressing, dependent with lower body dressing, personal hygiene, and putting on/taking off footwear. The resident also required substantial/maximal assistance with rolling, lying, sitting, and transfers, and is dependent on toilet transfers and walking. During the tour on 10/21/25 at approximately 12:33 PM, a Contact Precautions sign was observed above the room number where Resident #2 resided. An interview was conducted with the Unit Manager (UM) at 12:05 PM on 10/22/25. The UM stated that the resident's right foot wound presented with increased edema and purulent drainage; therefore, the wound care Nurse Practitioner (NP) obtained a specimen for analysis on 10/15/25.The UM further stated the resident's lab results were sent to the facility

on [DATE REDACTED], and Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis were growing in the right foot wound. The assessment based on the wound care NP's progress note, dated 10/20/25 at 12:48 PM, stated that the resident's right foot wound was deteriorating. The note stated that the right foot plantar wound measured 2.1 cm x 1.5 cm x 0.7 cm, had new tunneling 0.9 cm at 6 o'clock, and heavy sanguineous drainage was noted. The right foot had various tissues, including dermis (30%), granulation tissue (60%), and epithelium (10%).The UM stated that on 10/20/25, after the NPs reviewed the lab report and collaborated about the resident's right foot wound, orders were given to start the resident on

an intravenous (IV) antibiotic (Linezolid 600 mg BID for 3 days, followed by 300 mg BID as recommended by pharmacist given patient's renal function (Creatinine Clearance, 27), and to obtain a magnetic resonance imaging (MRI) to rule out osteomyelitis. On 10/22/25 at 12:05 PM, during the interview with the UM she stated that the resident had not received any doses of the IV antibiotic. The recount revealed that Linezolid Intravenous Solution 600 MG/300ML (Linezolid) Was Used 600 mg intravenously twice daily for a foot infection for 3 Days. This dose was scheduled to start at 8:00 AM on 10/21/25 and end at 8:00 PM on 10/23/25. The UM confirmed that on 10/21/25 at 8:00 AM, the resident had IV access, and the medication was available for administration. Still, she was unable to state why the medication was not administered. A further review revealed that on 10/21/25, the 8:00 PM dose of Linezolid was not administered because the IV had been dislodged. On 8/22/25 at 8:00 AM, the resident did not receive the antibiotic because the IV access remained dislodged. An IV was inserted on 10/22/25 at 10:32 AM, but the antibiotic was not given.

A 10/22/25 nurse's note at 1:00 PM stated the resident was to start the antibiotic that day, but it was not administered. On 10/23/25, a nurse's note at 1:30 PM stated that a consulting physician recommended discontinuing the antibiotic at that time and obtaining blood cultures and labs (ESR, CRP, arterial PVLs).A final interview was conducted on 10/23/25 at approximately 1:30 PM, and the above findings were shared with the Administrator, the Director of Nursing, a Corporate Consultant, and the [NAME] President of Operations. They had no comments and voiced no concerns regarding the above information.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nans Pointe Rehabilitation and Nursing

200 West Constance Road Suffolk, VA 23434

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).

The findings included: Resident #2 was initially admitted to the facility on [DATE REDACTED]. The resident's current diagnoses included an infected diabetic ulcer of the right foot. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/17/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated that Resident #2's cognitive abilities for daily decision-making were intact. In section GG (Functional Abilities and Goals), the resident was coded as requiring setup or clean-up assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with showers/bathes, and upper body dressing, dependent with lower body dressing, personal hygiene, and putting on/taking off footwear. The resident also required substantial/maximal assistance with rolling, lying, sitting, and transfers, and is dependent on toilet transfers and walking. During the tour on 10/21/25 at approximately 12:33 PM, a Contact Precautions sign was observed above the room number where Resident #2 resided. An interview was conducted with the Unit Manager (UM) at 12:05 PM on 10/22/25. The UM stated that the resident's right foot wound presented with increased edema and purulent drainage; therefore, the wound care Nurse Practitioner (NP) obtained a specimen for analysis on 10/15/25.The UM stated the resident's lab results were sent to the facility on [DATE REDACTED], and Staphylococcus aureus, Enterococcus faecalis, and Staphylococcus epidermidis were growing in the right foot wound. The UM further stated that the NP was not notified of the lab results until 10/20/25, for an unknown reason. The UM stated that the lab results are supposed to be viewable on the Point-Click-Care system dashboard, and the results should have been reported to the provider on the day they arrived at the facility. The UM also stated that, as a backup system to prevent missing labs and other pertinent information, the overnight shift is responsible for conducting a 24-hour chart check to identify oversights. Still, the oversight was not recognized until 10/20/25.The UM stated that

after the NPs reviewed the lab report, an order was given to start the resident on intravenous (IV) antibiotics and to obtain a magnetic resonance imaging (MRI) to rule out osteomyelitis.A final interview was conducted on 10/23/25 at approximately 1:30 PM, and the above findings were shared with the Administrator, the Director of Nursing, a Corporate Consultant, and the [NAME] President of Operations.

They had no comments and voiced no concerns regarding the above information. The facility's policy titled Culture and Sensitivity Lab Results, which was revised on 12/1/2022, stated at number 4b., that the 24-hour shift report may be used by nursing staff, nurse leaders, and the Infection Preventionist to identify residents who have pending lab results . 4d., report positive culture results to the physician/practitioner, including the antibiotics to which the identified pathogen is susceptible.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nans Pointe Rehabilitation and Nursing

200 West Constance Road Suffolk, VA 23434

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

spouse also said that presently, the resident is getting her knee stretched out by therapy to prevent contractures. Some days her legs hurt so bad she couldn't do therapy. Resident #3 lay in her bed nodding

in agreement. Resident #3 was asked to rate her knee pain on a pain scale out of 10. Resident #3 said her pain is a 10 but she just received Tylenol for Pain. Resident #3 says she's hurting now. Shortly thereafter, two facility staff were observed entering the resident's room with a Hoyer Lift to get resident up with her wheelchair with a Hoyer lift (11:48 am).On 10/22/25 at approximately 11:45 am., an interview was conducted with the Director of Rehabilitation (DOR). The DOR said that Resident #3 was admitted initially to receive a Physical Therapy (PT) evaluation on 9/19/25 and Occupational Therapy (OT) on 9/22/25. On 10/22/25 at approximately 1:00 pm., the DOR returned saying that he didn't see any notes written in his August 2025 calendar indicating there were PT, OT and ST evaluations.On 10/22/25 1:15 pm., an interview was conducted with the Business Office Manager (BOM) concerning the residents' insurance. The BOM said that the resident has had Medicare Part B. since 9/01/22, which was her therapy payor source but was pending Medicaid when she was first admitted to the facility.On 10/22/25 at approximately 2:20 pm., an

interview was conducted with Minimum Data Set Coordinator (MDSC). The MDSC said this was a standing order from 8/25/25 and that Our therapy department screens everyone that's admitted . The MDSC also said that therapy was decided by the resident's family.On 10/22/25 at approximately 4:15 pm., an interview was conducted with the Director of Nursing (DON). The DON said that the standing order was an admissions order that would normally be discussed in our daily meetings. The DON also said that therapy is given if necessary and usually once a resident is admitted they are evaluated for therapy in 7-10 days.On 10/23/25 at approximately 12:45 pm., a brief meeting was conducted with the administrator, BOM, The Social Services Coordinator and with the Corporate [NAME] President of Operations (VPOO). The VPOO said they missed the order to pick her up. A pre-exit interview was conducted on 10/23/25 at approximately 1:30 pm., the above findings were shared with the Administrator, The Corporate Consultant and the DON (Director of Nursing) and [NAME] President of Clinical Services. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nans Pointe Rehabilitation and Nursing

200 West Constance Road Suffolk, VA 23434

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited NANS POINTE REHABILITATION AND NURSING in SUFFOLK, VA for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-10-23.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 5 deficiencies cited during this inspection of NANS POINTE REHABILITATION AND NURSING.

Correction Status: Deficient, Provider has no plan of correction.