Kempsville Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Kempsville Health & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 18, 2022

  Based on observation, staff interviews, and clinical record review, the facility staff failed to provide care and services to prevent pressure ulcer development and to identify a pressure ulcer prior to progression to an advanced stage for 1 of 37 residents, (Resident #15) and the facility staff failed to ensure the necessary assessment, treatment, care, and services was provided for 1 of 37 Residents (Resident #278) impaired skin to prevent deterioration, necessitating surgical debridement which constituted harm. The findings included: 1. […]

• No harm, potential for more than minimal, isolatedF609Feb 26, 2026

  Based on interviews, record review, document review and facility policy review, the facility failed to ensure allegations of staff-to-resident abuse were reported timely, and in accordance with federal reporting requirements, to the State Survey Agency (SSA) for one of four sample residents (Resident (R) 101) reviewed for allegations of abuse or neglect. The facility's failure to promptly report allegations of abuse limited regulatory oversight and had the potential to delay protective interventions for residents.Findings include:Review of R101's undated Face Sheet located in the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbances, restlessness and agitation, and bipolar disorder. […]

• No harm, potential for more than minimal, isolatedF610Feb 26, 2026

  Based on interviews, record review, and facility policy review, the facility failed to investigate a potential injury of unknown origin for one of four sample residents (Resident (R) 101) reviewed for allegations of abuse. The facility's failure to thoroughly investigate the injury had the potential to delay protective interventions for residents.Findings include:Review of R101's undated Face Sheet located in the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbances, restlessness and agitation, and bipolar disorder. […]

• No harm, potential for more than minimal, isolatedF655Feb 26, 2026

  Based on record reviews, interviews, and facility policy review, the facility failed to ensure that a person-centered baseline care plan was developed within 48 hours of admission, and provided to the resident or their representative, for five of five residents (Resident (R) 105, R113, R59, R67, and R100) out of 20 sampled residents. This failure to establish initial care instructions for nursing staff placed newly admitted facility residents at risk of not receiving critical care needs, and residents and representatives to be poorly informed of anticipated plans of care.Findings include:1. Review of R105's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab indicated the resident was admitted to the facility on [DATE] and readmitted [DATE]. […]

• No harm, potential for more than minimal, isolatedF759Feb 26, 2026

  Based on observation, interview and review manufacturer's instructions for use, the facility failed to maintain a medication error rate below five percent. Out of the 27 opportunities for error, two errors occurred during medication administration with one of one Licensed Practical Nurse (LPN)3. The facility's medication error rate was 7.41%.Findings include:Observation of medication pass on the 400 unit the facility on 02/26/26 revealed the following medication errors:During medication administration with LPN3 on 02/26/25 at 09:01 AM, LPN3 injected 48 units of Lantus (Insulin Glargine - long-acting insulin) using an insulin pen into R110's abdomen and withdrew the insulin pen immediately.During an interview on 02/26/25 at 09:02 AM, LPN3 stated she was unaware of the manufacturer's… […]