Cycle 1
Health 2022-07-12 · Fire 2022-07-12
29 health deficiencies
Top issue: Infection Control (6 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Suffolk, VA
Nans Pointe Rehabilitation And Nursing
2-star overall rating with 1-star inspections with $5,293 in total fines with 29 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
200 West Constance Road, Suffolk, VA
(757) 539-8744
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
148
Certified beds
Average residents
127
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eastern Healthcare Group
Operator or chain grouping
Approved since
1991-06-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing
LPN hours / resident day
1.15
Licensed practical nurse staffing
Aide hours / resident day
1.88
Nurse aide staffing
Weekend hours
2.91
Weekend nurse staffing
RN turnover
80%
Annual RN turnover
Total nurse turnover
58%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.4
0.2 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 70.0% |
91.2%
21.2 pts worse
|
93.4%
23.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 68.1% |
94.0%
25.9 pts worse
|
95.5%
27.4 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.6%
2.7 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 14.4% |
15.7%
1.3 pts better
|
11.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.5% |
5.7%
2.2 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
20.2%
7.9 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 5.4% |
15.0%
9.6 pts better
|
16.7%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.7% |
17.5%
3.8 pts better
|
16.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
15.7%
2.4 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.5%
0.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.6%
0.1 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
22.2%
0.5 pts worse
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.2%
0.6 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 20.4% |
74.6%
54.2 pts worse
|
81.7%
61.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
11.7%
1.3 pts worse
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.2%
0.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 14.4% |
73.6%
59.2 pts worse
|
79.7%
65.3 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
22.0%
0.9 pts worse
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-16 · Fire 2019-05-16
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2017-08-10 · Fire 2017-08-10
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-07-12
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-12
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2022-08-12
C · Minimal harm
2022-07-12
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2022-08-19
C · Minimal harm
2022-07-12
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-08-19
C · Minimal harm
2022-07-12
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-08-19
C · Minimal harm
2022-07-12
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2022-08-19
D · Potential for more than minimal harm
2019-05-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2019-07-10
D · Potential for more than minimal harm
2019-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-10
D · Potential for more than minimal harm
2019-05-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-07-10
D · Potential for more than minimal harm
2019-05-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-07-10
D · Potential for more than minimal harm
2019-05-16
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-07-10
D · Potential for more than minimal harm
2019-05-16
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-07-10
D · Potential for more than minimal harm
2019-05-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-07-10
C · Minimal harm
2019-05-16
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-06-20
C · Minimal harm
2019-05-16
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2019-06-20
C · Minimal harm
2019-05-16
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2019-06-20
E · Potential for more than minimal harm
2017-08-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2017-11-02
E · Potential for more than minimal harm
2017-08-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2017-11-02
E · Potential for more than minimal harm
2017-08-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2017-11-02
E · Potential for more than minimal harm
2017-08-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2017-11-02
E · Potential for more than minimal harm
2017-08-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2017-11-02
D · Potential for more than minimal harm
2017-08-10
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2017-11-02
D · Potential for more than minimal harm
2017-08-10
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2017-11-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-23
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Not marked corrected
D · Potential for more than minimal harm
2025-10-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Not marked corrected
D · Potential for more than minimal harm
2025-10-23
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Not marked corrected
D · Potential for more than minimal harm
2025-10-23
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Not marked corrected
D · Potential for more than minimal harm
2025-10-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
G · Actual harm
2022-07-12
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-08-19
F · Potential for more than minimal harm
2022-07-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-08-19
F · Potential for more than minimal harm
2022-07-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-15
F · Potential for more than minimal harm
2022-07-12
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-07-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-07-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-07-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-07-12
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-07-12
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-07-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-12-15
E · Potential for more than minimal harm
2022-07-12
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-07-12
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-07-12
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-07-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-07-12
F620 · Resident Rights Deficiencies
Health
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-07-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-07-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-07-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-07-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-07-12
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-07-12
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-07-12
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-07-12
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-07-12
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-08-19
E · Potential for more than minimal harm
2019-05-16
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-06-20
E · Potential for more than minimal harm
2019-05-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-16
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-16
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-16
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-16
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-06-20
E · Potential for more than minimal harm
2017-08-10
F278 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment by a qualified health professional.
Corrected 2017-09-22
E · Potential for more than minimal harm
2017-08-10
F333 · Pharmacy Service Deficiencies
Health
Ensure that residents are safe from serious medication errors.
Corrected 2017-09-22
D · Potential for more than minimal harm
2017-08-10
F224 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from mistreatment, neglect and misappropriation of personal property.
Corrected 2017-09-22
D · Potential for more than minimal harm
2017-08-10
F285 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients.
Corrected 2017-09-22
D · Potential for more than minimal harm
2017-08-10
F315 · Quality of Life and Care Deficiencies
Health
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
Corrected 2017-09-22
D · Potential for more than minimal harm
2017-08-10
F431 · Pharmacy Service Deficiencies
Health
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Corrected 2017-09-22
B · Minimal harm
2017-08-10
F167 · Resident Rights Deficiencies
Health
Allow residents to easily view the results of the nursing home's most recent inspection.
Corrected 2017-09-22
Penalties and ownership
What sits behind the stars
$5,293
2023-06-12
Fine
Fine · fine $5,293
Fine
Ownership
Va SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Bryant, Tameika
W-2 Managing Employee · Individual
Jj United Tr
5% Or Greater Indirect Ownership Interest · Organization
Shapiro, Akiva
Corporate Officer · Individual
Ydi Eastern Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Ydi Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
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