Old Dominion Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Old Dominion Rehabilitation and Nursing, in the surveyor’s own words.

• Immediate jeopardy, patternF600Feb 20, 2026

  Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from sexual abuse for two of nine residents reviewed for abuse (Resident (R) 2 and R122) out of 41 sampled residents. R2 experienced repeat sexual victimization when she was sexually abused by her Power of Attorney (POA2) in the facility, R121, and R100. Additionally, R122 was sexually abused by R99. Even though the facility was aware of R121's, R100's, and R99's incidents of sexual abuse and sexual behavior, the facility failed to put measures in place to protect R2, R122, and other vulnerable residents from sexual abuse, which constituted immediate jeopardy (IJ). Findings include:1. […]

• Actual harm, isolatedF602Feb 20, 2026

  Based on interviews, record review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation for one of three residents (Resident (R) 120) reviewed for misappropriation out of 41 sampled residents. The Business Office Manager (BOM) used the resident's credit card for personal use, totaling over $10,000. This failure resulted in more than minimum consequence harming Resident #120 by deliberately misusing and exploiting significant amounts of money without consent which constituted Immediate Jeopardy past non-compliance. […]

• No harm, potential for more than minimal, widespreadF880Feb 20, 2026

  Based on interviews, record review, and facility policy review, the facility failed to complete an assessment of the building to determine where Legionella and other opportunistic waterborne pathogens can grow and spread. Additionally, the facility failed to ensure staff adhered to Transmission Based Precautions (TBP) for one of 41 sampled residents (Resident (R) 51). These failures had the potential for some of the areas at risk for Legionella growth not to be monitored in the building and placed residents at risk for the spread of infections.Findings include:1. Review of the facility's Water Management Binder, provided by the facility, revealed an assessment of the building was not completed where Legionella could grow and spread. […]

• No harm, potential for more than minimal, patternF609Feb 20, 2026

  Based on interview, record review, and facility policy review, the facility failed to report alleged abuse violations timely for five of five Residents (Resident (R) 2, R99, R100, R121 and R122) reviewed for abuse out of a total sample of 41 residents. This had the potential for continued abuse. Findings include:1. Review of the Facility Reported Incident (FRI) provided by the facility revealed there was an allegation of sexual abuse between R2 and R121 which occurred on 05/17/25 at 12:15 PM. The allegation was not reported to the State Agency (SA) until 05/18/25 at 10:50 PM (over 34 hours later). 2. Review of the FRI provided by the facility revealed an allegation of abuse between R2 and R100 occurred on 07/02/25. […]

• No harm, potential for more than minimal, patternF628Feb 20, 2026

  Based on interview, record review, and policy review, the facility failed to ensure residents and/or resident representatives were provided with written notices of transfer and bed hold notices for four of five residents (Residents (R) 5, R8, R51, and R99) reviewed for hospitalizations out of a total sample of 41. This failure had the potential for residents and/or resident representatives (RP) not to have the necessary information to make informed decisions regarding bed holds and to not be informed of the reasons for transfers. Findings include:1. Review of R5's undated admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R5 was admitted to the facility on [DATE]. […]