Nans Pointe Rehabilitation And Nursing
NANS POINTE REHABILITATION AND NURSING in SUFFOLK, VA — inspection on April 25, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
conducted with the Administrator, Regional [NAME] President of Operations, [NAME] President of
Care Facilities, AHA Data & Insights, 2020 The American Society for Health Care Engineeing of the
(SOM): Appendix 1 (Life Safety Code Health Care Facilities Code, 2012 edition). K901 - Building System Categories.National Fire Proteection Association (NFPA), NFPA 99-2012.
Chapter 4.
495247 04/25/2026
Nans Pointe Rehabilitation and Nursing 200 West Constance Road Suffolk, VA 23434
According to the Administrator, he confirmed that the facility was on Fire Watch.
When asked what being on Fire Watch meant? He stated that someone was making rounds every 15 minutes or so walking the halls and rounding outside to look for any signs of smoke or fire. He stated the Fire Watch duties had been done primarily by the nursing staff as they were already in the building 24 hours a day, 7 days a week.
When asked why the facility was on Fire Watch, he stated he was not sure of the exact issue, however the Life Safety inspector had identified the fire panel malfunctioning during a 4/15/26 Life Safety Inspection. He stated he had signed a contract 4/23/26 with the facility's Fire, Safety & Security vendor (name Redacted) to replace the facility's fire alarm system, however it would be sometime in July 2026 before system was fully functioning. He also stated that the Life Safety Inspector had been in earlier that day and said the facility was required to initiate a dedicated person to Fire Watch who could not do any other tasks except to patrol the facility for fire safety.
When asked who was on Fire Watch duty currently, he gave first name of receptionist (name redacted) but could not recall her last name. A review of the fire maintenance binder revealed Fire Watch logs dating back to 1/30/26.
The Administrator was asked why the facility was on Fire Watch as far back as 1/30/26 and according to him, he was not quite sure as he had just started as Administrator March 30, 2026, but was told the system had been touch and go as far back as end of 2025.
The Administrator said the vendor had been in recently and verified panel was functioning.
When asked for credible evidence to support that the Fire, Safety and Security vendor (name redacted) had been in and verified panel was functioning he said he did not have a copy of the visit report but would try and get something from the vendor. He presented a copy of the signed contract dated 4/23/26 and a copy of the Plan of Correction for the Life Safety Inspection citing the fire panel, smoke detectors and exit signage not functioning properly.
When asked if he had any evidence that the facility was conducting audits on the fire panel functionality or testing, fire alarm system inspections, maintenance program records, he did not have anything to present to surveyor. He stated the facility does not currently have a full-time maintenance director.
When asked if the facility had addressed the malfunctioning of the fire panel or smoke detectors and facility being on Fire Watch since January 2026 to their (QAPI) Quality Assurance and Performance Improvement Committee, he stated that he was not aware of it. He presented a copy of the facility's QAPI Agenda/Minutes form which identified a section for Maintenance: Fire Drill Log, Disaster Drill Log, Fire Alarm test monthly, maintenance tracking report use and Elopement Drills.
When asked if the issue should have been addressed in the QAPI committee, he replied, Most definitely, it should have been reported to QAPI.A copy of the facility's policy on administration or administrative duties was requested.
The Administrator stated they did not have a policy addressing administrative duties.On 4/28/26 at 5:24 PM, an exit meeting was conducted with the Administrator, Regional [NAME] President of Operations, [NAME] President of Plant Operations and Owner/Partner and were offered an opportunity to present additional information. No further information or comments were provided.
495247 04/25/2026
Nans Pointe Rehabilitation and Nursing 200 West Constance Road Suffolk, VA 23434
Guidance for Surveyors for Long Term Care Facilities (November 2017). F-F837- Governing Body
495247 04/25/2026
Nans Pointe Rehabilitation and Nursing 200 West Constance Road Suffolk, VA 23434
door and stated that the door had been repaired.
When asked if he had the credible evidence to show
which included the signatures of the Administrator, Director of Nursing and Infection Preventionist
Administrator stated he did not have any evidence of quarterly QAPI meetings for the past year.
When asked if he had credible evidence that the facility had addressed the issue of the fire panel malfunctioning and that the facility had been on Fire Watch since 1/30/26 he stated he could not locate any evidence that these issues had been addressed by the facility's QAPI committee. He presented a copy of the facility's Agenda/Minutes form which identified a section for Maintenance: Fie Drill Log, Disaster Drill Log, Fire Alarm test monthly, TELS use and Elopement Drills.
When asked if the issue should have been addressed in the QAPI committee, he replied, Most definitely, it should have been reported to QAPI.A review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) dated 2021, reads in part; Procedure: The primary goals of the QAPI committee are to: 1) Establish, maintain, and oversee facility systems and processes to support the delivery of quality care and services. 2) Promote the consistent use of facility systems and provisions of care and services. 3) Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately.4) Support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systematic problems. 6) Coordinate the development, implementation, monitoring, and evaluation of performance improvements projects to achieve specific goals; Committee Reports and Records: The committee shall maintain minutes of all regular and special meetings that include date/time, attendance, summary of reports and findings, a summary of any approaches and action plans, conclusions and recommendations.On 4/28/26 at 5:24 PM, an exit meeting was conducted with the Administrator, Regional [NAME] President of Operations, [NAME] President of Plant Operations and Owner/Partner and were offered an opportunity to present additional information. No further information or comments were provided.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.