Maimonides Health Center Of Virginia Beach

The survey team reviewed the PNC POC documents. It was determined by the survey team through interviews, record reviews and resident observations that the above practices were not identified since 9/29/25 nor during the course of the survey from 11/12/25 through 11/17/25.

On 11/17/25 at approximately 4:25 p.m., the above findings were shared with the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and via telephone the local Ombudsman was present. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. It was determined that the facility implemented its Corrective Action Plan, and there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the regulatory requirements, F-F600 at Past Non-Compliance.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Maimonides Health Center of Virginia Beach

6401 Auburn Dr Virginia Beach, VA 23464

SUMMARY STATEMENT OF DEFICIENCIES

Provide care and assistance to perform activities of daily living for any resident who is unable.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on family and staff interviews, clinical record review and facility document review the facility staff failed to provide adequate bathing and ADL care to a dependent resident (Resident #2) in a survey sample of 10 residents.The findings included.Resident #2 was admitted on [DATE] with diagnoses including nephrostomy tubes for urine excretion, chronic heart failure and chronic heart disease with 3 cardiac arterial bypass grafts, an artificial heart valve, and a left ventricular ejection fraction of only 26% revealing a severely weakened heart muscle.

The Resident's admission weight was 120 pounds, and she used oxygen in the hospital and was ordered to be administered Oxygen at 3 liters per minute via nasal cannula as needed upon discharge.The Resident's Activities of Daily Living (ADL) records were reviewed and revealed bathing and showering records.

Those records indicated that Resident #2 received a bed bath only 3 times, on 1-23-25, 1-24-25, and 3-2-25.

Documents recorded refusals to be bathed by the Resident only twice, on 2-10-25, and 3-1-25. No other baths nor showers were provided to Resident #2 during her entire 43-day stay in the facility.Resident #2 had nephrostomy tubes and at times those are known to leak causing a need for frequent bathing.

They are inserted into the lower back of a resident to provide a way for urine to flow directly from the kidneys to the outside of the body.

The underlying reason for nephrostomy tube surgical insertion is due to a blockage in the normal pathway of urine exit from the body.

Movement, while in bed, can compress or disrupt the skin in the areas where the tubes exit the body and interfere with the seal of the tubes in the skin.

Staff members (2 LPNs licensed practical nurses and 2 CNAs Certified Nursing Assistants) on the unit where this Resident formerly resided were asked how often bathing was provided to the residents.

The response by all was 2 times per week for showers or tub baths, and every day if they received bed baths.Other Residents were placed in the survey sample and reviewed for hygiene care which was found to be adequate. No pervasive odors, nor soiled linens on beds were found.

Residents and family members were interviewed and had no issues with hygiene care being provided.On 11-17-25 at 3:00 p.m., at the end of day debriefing held with the Director of Nursing (DON), and Assistant Director of Nursing (ADON), they were informed by surveyors of the staff failure to provide adequate bathing required for this dependent Resident.

Both stated they had nothing further to provide.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Maimonides Health Center of Virginia Beach

6401 Auburn Dr Virginia Beach, VA 23464

SUMMARY STATEMENT OF DEFICIENCIES

further stated that 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 (7) seven year nursing career and being really shook up. LPN #3 lastly stated, I left the room and when I came back to the room, the Resident was in her bed. 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 not responding and did not have a pulse.

She had blood coming from her head.

She had only been here a few days and I did not know her functional abilities.

The facility's Fall policy was presented on [DATE] at 11:20 AM from the Assistant Director of Nursing (ADON) without an effective date.

The policy read: Do not move resident until assessment has been completed by the nurse.

The Physician's Order Summary (POS) for [DATE] read: Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for a fib with a start date of [DATE].A review of Resident #1's nurses note (Unit Manager) dated [DATE] at 18:14:49 PM read, Late Entry: Note Text: Nurse and CNA went to resident's room at 0730 to assist the resident for her shower.

Resident requested to use the toilet prior to taking a shower and asked the CNA to step out for privacy.

Resident was educated to use the call bell when in need of assistance.

Call bell was in place.

Shortly after, CNA heard a noise indicating something had fallen. CNA immediately went to the bathroom to check the resident. At 0740, nurse was notified that resident was found lying on the bathroom floor.

Nurse promptly responded and assessed the resident.

Resident was unresponsive. At approximately 0803, writer was alerted about the incident.

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 has a Do Not Resuscitate order in place.

Hoyer lift was utilized by two staff to move the resident from the floor to bed. RP/Daughter was informed of the resident's status at 0810. MD was notified at 0820.

The resident was pronounced dead by [NAME] NP at 0930.

Family came in the facility at 1000.

Writer communicated the resident's death to the family with compassion and sensitivity.

The family expressed their understanding of the DNR status and shared feeling of loss.

Daughter inquired about funeral arrangements and information was provided.

The body was respectfully prepared for transport. It was picked up by [NAME] Funeral Home at 1130. On [DATE] at 1:43 PM an interview was conducted with the Rehab Manager.

The Rehab Manager stated that Resident #1 required supervision or touching assistance with transfers.

The Rehab Manager also stated that supervision or touching assistance with transfers means that the 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.

The Rehab Manager further stated that Resident #1 required supervision using her front wheeled walker while performing commode transfers. A review of Resident #1's Physical Therapy Evaluation and Plan of Treatment with a start of care date of [DATE] read: Transfers - Baseline: Supervision or touching assistance. A review of Resident #1's Occupational Therapy Evaluation and Plan of Treatment with a start of care date of [DATE] read: Toileting hygiene - Baseline: Partial/moderate assistance.

Toilet/adapted commode transfers - Baseline: Supervision using front wheeled walker. On [DATE] at approximately 4:15 PM, a final interview was conducted with the Director of Nursing and Assistant Director of Nursing. An opportunity was offered to the facility's staff to present additional information.

They had no further comments and voiced no concerns regarding the above information.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Maimonides Health Center of Virginia Beach

6401 Auburn Dr Virginia Beach, VA 23464

SUMMARY STATEMENT OF DEFICIENCIES

This reveals that the edema, weight gain, and shortness of breath were indeed symptoms of a worsening illness, and not related to fluid consumption nor noncompliance.On 11-17-25 at 3:00 p.m., at the end of day debriefing held with the Director of Nursing (DON), and Assistant Director of Nursing (ADON), they were informed by surveyors of the staff failure to provide adequate hydration required for this dependent Resident.

Both stated they had nothing further to provide.

Facility ID: