Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cypress Pointe Rehabilitation And Nursing during CMS and state inspections, most recent first.
A dependent, cognitively impaired resident with dementia, depression, and muscle weakness, coded as requiring total assistance for rolling in bed, fell from bed during ADL care when a CNA turned away to rinse a washcloth. At the time of the fall, the bed was not lowered and ordered floor mats were not in place. Staff later documented progressive swelling, bruising, and pain in both lower legs and ankles, and imaging ultimately showed acute fractures of the distal tibia and fibula. Interviews with an LPN, MDS nurse, Rehab Manager, and DON confirmed that the resident was totally dependent, would not follow commands, and should have been safely positioned in the middle of the bed before the CNA turned away, indicating inadequate supervision and failure to follow fall‑prevention measures.
Two cognitively intact, dependent residents did not receive necessary ADL and incontinence care. One resident with a history of CVA, COPD, and GI bleed, care-planned for mechanical lift transfers and two-person toileting assistance, reported only receiving bed baths on night shift, being denied use of a shower chair despite requesting showers to protect her hair, and experiencing long delays in toileting and incontinence care from early morning until after lunch, even after activating the call light. Staff required use of a Hoyer lift, which the resident feared, and a CNA confirmed that incontinence care was routinely delayed and that the resident was not toileted because she used a Hoyer. Another resident with chronic pain, insomnia, COPD, obesity, and documented ADL self-care deficits reported remaining wet for prolonged periods, including from late night until morning, and stated that it often took 30–60 minutes or more for staff to respond, sometimes requiring her to call her son to contact the nurse’s station.
A cognitively intact resident with right-sided weakness and ADL deficits reported that CNAs routinely provided a bed bath, dressed her, and transferred her early in the morning but did not offer toileting every 2–3 hours as expected. She stated that when she used the call light for toileting or incontinence care, staff would respond, say they needed another CNA due to Hoyer lift use, and then not return for hours, often not until after lunch, resulting in frequent incontinence and straining for bowel movements. An Ombudsman confirmed frequent complaints about incontinence care, bathing, toileting, and repositioning. A CNA acknowledged that incontinence care was typically not provided until after lunch and that the resident was not toileted because she used a Hoyer lift, and also reported never seeing a toileting-specific Hoyer pad. Facility leadership later asserted that special equipment and less-restrictive transfer interventions were available for the resident but could not produce documentation to support this.
The facility failed to have a qualified infection preventionist (IP) to manage the infection prevention and control program. The current IP, a Registered Nurse, had not completed the required competency test for certification, despite having completed the training. This issue was identified during a review of infections, where two residents had multiple UTIs over six months. The last qualified IP left the facility, and the current IP assumed the role without certification. No concerns were raised by the administration regarding this deficiency.
A resident with multiple diagnoses, including peripheral vascular disease and pressure ulcers, did not receive prescribed pain medication for approximately 38 hours due to a mix-up in the medication administration record. The resident, who was cognitively intact, experienced significant pain and had an order for Oxycodone 10mg every four hours as needed. The error was discovered after the resident's family member intervened, leading to a review by the nursing supervisor and LPN, who then administered the medication.
A facility failed to document 50 doses of oxycodone on the MAR for a resident, despite these doses being signed out on control records. The resident had multiple medical conditions, including pain and pressure ulcers. The DON acknowledged the lack of an auditing process, and an LPN admitted to not consistently documenting due to feeling rushed. The findings were shared with the administration.
Failure to Provide Adequate Supervision During Bedside ADL Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a hazard‑free environment during ADL care for one dependent resident, resulting in a fall with fractures. The resident had diagnoses including unspecified dementia without behavioral disturbance, major depressive disorder, and muscle weakness, and was coded on the MDS as dependent for rolling left and right in bed, meaning the helper did all of the effort. The resident was also coded as rarely/never understood, so no BIMS was completed. Facility orders included the use of floor mats to the side of the bed while the resident was in bed for safety related to frequent falls. On the date of the incident, a CNA was providing ADL care to the resident while the resident was in bed. According to nursing documentation and staff interviews, the CNA turned her back to rinse a washcloth, during which time the resident rolled out of the bed onto the floor. LPN interview and nursing notes indicated that the bed had not been lowered and fall mats were not in use at the time of the fall, despite existing orders for floor mats. Staff, including the MDS nurse, Rehabilitation Manager, and DON, stated that the resident was totally dependent for ADLs, would not follow commands, and that the CNA should have ensured the resident was safely positioned in the middle of the bed before turning away. Following the fall, nursing documentation described that the resident was assessed and initially noted to have a small skin issue on the left lower arm, with no immediate signs of distress or pain. Over the next several days, nurses documented bilateral lower leg and ankle swelling, bruising, and obvious pain during ADL care. X‑rays of the bilateral ankles and feet were ordered and performed, and radiology results later identified acute‑appearing fractures of the distal tibia and fibula with posterior and medial angulation, as well as a fibular fracture. The resident was subsequently sent to the hospital and was reported to be admitted with bilateral tibial fractures. The facility’s own fall prevention and management policy referenced assessing fall risk factors including the resident’s current ADL status, but the actions taken during the ADL care did not prevent the fall for this dependent resident.
Failure to Provide Timely ADL and Incontinence Care to Two Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary ADL care, including bathing, toileting, and incontinence care, to two cognitively intact, dependent residents. One resident, with a history of stroke with right-sided weakness, GI bleed, and COPD, had a care plan identifying ADL self-care deficits and specifying use of a mechanical sit-to-stand lift with two staff for transfers, two-person assist for toileting, and individualized interventions for bathing, dressing, and clothing selection. Despite this, the resident reported that night-shift CNAs routinely provided only bed baths, dressed her, and transferred her to a wheelchair around 5:30 AM, and that she was not offered showers as desired. She stated she wanted showers using a shower chair to avoid getting her hair wet and undoing professional hair styling, but staff insisted on using a shower bed and documented her as refusing showers when she would not agree to the shower bed. The same resident reported significant delays and lack of toileting assistance throughout the day. She stated she was aware of her need to toilet but had to wait so long for assistance that she often urinated in her incontinence brief and had to strain to have bowel movements while waiting for staff. She reported not being offered toileting every 2–3 hours as she had been told was the expectation and not receiving incontinence care from approximately 5:30 AM until after lunch, at which time her brief was described as extremely saturated. She also stated that when she activated the call light, staff would respond, acknowledge her need, say they needed to get help, and then not return for hours, often not until after lunch. The resident expressed fear of the Hoyer lift and stated she was strong enough to use a sit-to-stand lift, but staff required Hoyer use for transfers. The Ombudsman confirmed frequent complaints from this resident about incontinence care, bathing, toileting, and repositioning, and a CNA reported that the resident was not toileted because she used a Hoyer lift and that incontinence care was routinely delayed until after lunch. A second resident, originally admitted with diagnoses including chronic pain and insomnia and assessed as cognitively intact with a BIMS score of 15, was coded on the MDS as dependent for showering/bathing, toileting hygiene, lower body dressing, and footwear, and as needing assistance with personal and oral hygiene. The person-centered care plan identified an ADL self-care performance deficit related to COPD and obesity, with interventions including encouraging the resident to use the call bell and discussing concerns about loss of independence and decline in function. This resident reported that for about one and a half weeks she had not been changed for hours and had to lie in her own wetness, stating it took 30 minutes to an hour before staff checked on her and that she sometimes called her son to contact the nurse’s station. In a follow-up interview, she reported remaining wet from late at night until after 7:00 AM the next morning. The facility leadership was unable to provide additional information to refute or clarify these concerns during the final interview.
Failure to Provide Timely Toileting and Incontinence Care for Cognitively Intact Resident
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to assist Resident #79 in achieving and maintaining bowel and bladder control and dignity in toileting and incontinence care. Resident #79, who had a history of stroke with right-sided weakness, GI bleed, and COPD, was cognitively intact per a BIMS score of 15/15 and had a care plan identifying ADL self-care deficits with goals to improve function. The care plan interventions included use of a mechanical sit-to-stand lift with two staff for transfers and two-person assist for toileting, as well as support for bathing and dressing. Despite this, the resident reported that night-shift CNAs routinely provided a bed bath, dressed her, and transferred her to a wheelchair at 5:30 AM, and that she was not offered toileting every 2–3 hours as she had been told was the expectation by licensed nursing staff. Resident #79 stated she was aware of her need to toilet but had to wait extended periods for assistance because staff required use of a Hoyer lift, which needed two CNAs. She reported that when she used the call light, staff would respond, state they needed to get help, and then not return for hours, often not until after lunch, resulting in her frequently urinating in her brief and having to strain to have bowel movements while waiting. She further stated she did not receive any bowel or bladder care from 5:30 AM until after lunch, and that when incontinence care was finally provided, her brief was extremely saturated. The Ombudsman confirmed frequent complaints from the resident about incontinence care, bathing, toileting, and repositioning. CNA #4 acknowledged checking on the resident but not providing incontinence care until after lunch and stated the resident was not toileted because she used a Hoyer lift, and that she had never seen a special Hoyer pad for toileting or showers. During the final interview, facility leadership claimed such a special Hoyer pad and less-restrictive transfer interventions existed for the resident, but they were unable to provide any documentation or evidence of these interventions.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist (IP) to oversee the infection prevention and control program. During a review of infections acquired in the facility, it was found that the current IP, a Registered Nurse, had not completed the competency test required for certification, despite having completed the training. This deficiency was highlighted during an interview on 7/3/24, where the IP could not provide documentation of the curriculum for staff education on urinary tract infections (UTIs), despite two residents having multiple UTIs over a six-month period. The last qualified IP had left the facility on 12/22/23, and since then, the current IP had been fulfilling the role without the necessary certification. In a final interview on 7/8/24 with the Administrator, Director of Nursing, and Regional Nurse Consultant, no comments or concerns were raised regarding the lack of a qualified IP. This indicates a lapse in ensuring that the infection prevention and control program is managed by a certified individual, potentially impacting the quality of care provided to residents.
Failure to Administer Pain Medication
Penalty
Summary
The facility staff failed to administer pain medication to a resident, identified as Resident #7, who experienced significant pain and requested medication. Resident #7, who was cognitively intact, was admitted with multiple diagnoses including left leg pain, peripheral vascular disease, a right below-knee amputation, and pressure ulcers. Despite having an order for Oxycodone 10mg every four hours as needed for pain, the resident went without pain medication for approximately 38 hours. The issue arose when the nursing staff mistakenly believed that Resident #7 had already received his medication, leading to a prolonged period of unmanaged pain. The confusion was compounded by a mix-up in the medication administration record and the narcotic book, where it was incorrectly noted that Resident #7 had received his pain medication. This error was discovered after the resident's family member intervened, prompting a review of the records by the nursing supervisor and LPN. It was then realized that the medication had not been administered, and the resident was subsequently given the prescribed Oxycodone. The facility's pain management policy, which mandates pain management for residents requiring such services, was not adhered to in this instance, as evidenced by the lack of a pain assessment and the failure to administer medication as ordered.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility staff failed to document the administration of 50 doses of oxycodone on the Medication Administration Record (MAR) for one resident, despite these doses being signed out on the medication monitoring control records for December 2023 and January 2024. The resident, who was admitted with conditions including left leg pain, peripheral vascular disease, a right below-the-knee amputation, and pressure ulcers, had a care plan focusing on the risk for alteration in comfort. However, the MARs for the specified months did not reflect the administration of oxycodone on numerous occasions, indicating a lapse in proper documentation. Interviews conducted during the survey revealed that the Director of Nursing (DON) acknowledged the lack of a process for auditing controlled medication sheets and expressed intentions to develop one. Additionally, an LPN admitted to not consistently documenting controlled medications on the MAR due to feeling rushed and the fast-paced nature of her shifts. This LPN had previously been educated by the DON on the importance of complete documentation. The findings were shared with the facility's administration, but no further information was provided before the survey concluded.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Virginia Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Taylor Hosp | 1.9 mi | — | 5 | 0 |
| Waterside Health & Rehab Center | 2.1 mi | — | 0 | 0 |
| Bayside Health & Rehabilitation Center | 2.2 mi | — | 0 | 0 |
| Autumn Care Of Norfolk | 2.4 mi | — | 0 | 0 |
| Thalia Gardens Rehabilitation And Nursing | 3.4 mi | — | 31 | 0 |
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