Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hampton Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not maintain adequate nursing staff coverage, particularly on weekends and certain shifts, resulting in unmet resident care needs such as long wait times for assistance, missed showers, and resident frustration. Staffing records and interviews confirmed frequent call-ins, difficulty filling open positions, and reliance on bonuses to encourage staff to work extra shifts, but these measures were insufficient to ensure consistent coverage.
Residents reported that their care needs were frequently unmet due to insufficient staffing and the conduct of a specific aide, resulting in long wait times for assistance, missed showers, and lack of help with meals. Multiple residents described being treated disrespectfully, with one aide characterized as rushed and rude, leading to feelings of diminished self-worth and unmet needs.
Surveyors found that the facility failed to maintain clean and safe shower rooms, with black residue, chipped tiles, and a non-functioning shower, resulting in an environment that did not meet regulatory standards for cleanliness and comfort.
Surveyors found that the facility did not follow care plans for ADL and wound care for three residents, resulting in missed showers, inadequate hygiene, and a missed dressing change for a post-surgical wound. Documentation was inconsistent, and required interventions for refusals or missed care were not in place.
Multiple dependent residents did not receive scheduled showers or bed baths, resulting in poor hygiene, greasy hair, body odor, and unshaven appearances. Only one shower was available for all residents due to facility infrastructure issues, and care plans lacked interventions for refusals or alternative hygiene measures. Residents expressed dissatisfaction and emotional distress, and documentation did not reflect appropriate hygiene care or strategies for managing refusals.
A resident with a post-surgical back incision did not receive a daily dressing change as ordered, with observation showing the same dressing in place for two days. Nursing staff documented the dressing change as completed, but the physical evidence and resident interview indicated otherwise. The DON confirmed that dressing changes should be completed as ordered and by the next shift if missed.
A resident with severe cognitive and physical impairments, identified as very high risk for pressure injuries, was repeatedly found without required positioning devices and developed multiple open areas of skin breakdown under the left breast. Staff failed to follow care-planned interventions for repositioning and did not document or report the new skin breakdown, despite clear risk factors and facility guidelines.
A medication cart was found unlocked and unattended in a hallway, allowing access to medications by residents, visitors, and staff. The assigned RN was in a resident's room at the time, and the cart was accessible to the state surveyor, who was able to open its drawers. The RN had previously received inservice training on the requirement to keep medication carts locked when not in use, and facility policy prohibits leaving carts unlocked and unattended.
A resident who refused the RSV vaccine did not have a signed refusal form or documentation of vaccine education in the medical record. The electronic record included a blank consent form, and no progress notes indicated that education or refusal was addressed, even after the resident was readmitted with RSV.
A deficiency was cited due to the facility not being fully protected by an approved automatic sprinkler system as required by the 2012 standards for existing nursing homes and hospitals.
Surveyors found that the facility basement, which houses the laundry, employee break room, maintenance office, boiler room, storage, electrical room, and employee bathroom/locker room, had only one exit instead of the two required by NFPA 101. This deficiency was confirmed by interviews with facility leadership and could affect about 10 occupants in an emergency.
Surveyors found that a sprinkler head in the main lobby near the front egress door was installed too close to a light fixture, in violation of NFPA 13 requirements. This placement could alter the water flow pattern and does not provide proper sprinkler protection, as confirmed by interviews with facility leadership.
The facility failed to ensure that call lights and privacy curtains were accessible to residents, leading to unmet care and privacy needs. Observations showed that privacy curtains were out of reach in several rooms, and a resident's call light was placed four feet away, making it inaccessible. A CNA admitted to not using the privacy curtain during a care task, further compromising resident privacy.
The facility failed to provide adequate ADL care for four residents, leading to issues such as long fingernails, missed showers, and unkempt appearances. One resident missed scheduled showers, another had long nails and dirty palms, a third reported missed showers due to staff availability, and a fourth was left in a nightgown for days with their call light out of reach. These deficiencies indicate a failure to adhere to the facility's policy on maintaining residents' ability to perform ADLs.
A resident developed a facility-acquired pressure injury on the left heel due to the facility's failure to prevent it and ensure timely nutritional care plans. Despite being alert and oriented, the resident experienced significant weight loss and inconsistencies in receiving prescribed nutritional interventions. Interviews revealed a lack of awareness and follow-up by the dietary manager and registered dietician regarding the resident's nutritional needs and preferences.
A resident with contracted hands was observed multiple times without the required bilateral palm protectors, as specified in their care plan. The Therapy Director confirmed the need for these protectors during the day, but they were found unused in the resident's nightstand. The resident's care plan included instructions for applying the protectors, and staff had been educated on their use.
A nurse improperly stored narcotics for a resident by placing them in a medication cart drawer instead of following proper storage procedures. The nurse prepared the medications, including Norco and Pregabalin, and when the resident requested to take them later, the nurse stored them in the drawer. The Director of Nursing acknowledged the error, noting it was against the facility's Controlled Substances Policy.
A resident experienced significant weight loss due to the facility's failure to honor her dietary preferences and provide palatable meals. Despite being on a Controlled Carbohydrate Diet and No Added Salt diet, the meals served were high in carbohydrates and sugar, contrary to her needs for managing Type 2 Diabetes. The resident's documented preferences, such as the inclusion of strawberries and cottage cheese, were not followed, leading to reduced food intake and frustration.
A facility failed to ensure proper communication and documentation of hospice services for a resident, leading to a lack of progress notes and assessments in the medical record. The resident was found uncomfortable, and the unit nurse had not notified the hospice agency about symptoms. The hospice services binder lacked documentation, and there was a delay in scanning progress notes into the EMR. Additionally, Morphine Sulfate was administered at incorrect intervals, with no changes in the prescribed order noted.
The facility failed to implement Enhanced Barrier Precautions, as staff were observed not wearing required PPE in designated rooms. A nurse and a CNA were seen without gowns during high-contact activities, and a housekeeper cleaned an EBP room without a gown. These actions violated the facility's policy and physician orders, risking cross-contamination.
Deficiency Due to Insufficient Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure adequate nursing staff to meet the needs of residents, as evidenced by multiple resident interviews and review of staffing records. Residents reported long wait times for assistance, particularly on weekends and during certain shifts, with one resident stating she waited 30-45 minutes for help and experienced incontinence as a result. Several residents expressed frustration about insufficient staff coverage, especially on weekends and second shift, and noted that call lights were not answered promptly. Review of the facility's PBJ (Payroll-Based Journal) staffing data for the first quarter of 2025 revealed low weekend staffing. The facility's policy states that sufficient numbers of licensed nurses and CNAs are to be available 24/7, but interviews with staff and review of schedules indicated frequent call-ins and difficulty filling open positions, particularly on weekends. The facility attempted to address call-ins by offering bonuses and asking staff to stay over, but gaps in coverage persisted. The Human Resources staff confirmed that agency staff were not used and that new hires often did not remain after orientation, further contributing to staffing shortages. Staffing levels discussed included a requirement for 4 CNAs and 2 nurses on day and afternoon shifts, and 1-2 CNAs and 2 nurses on night shift, depending on census. Despite these requirements, both residents and staff reported that actual staffing often fell short, especially on weekends. The facility's inability to consistently provide sufficient nursing staff resulted in unmet resident care needs, including missed showers and delayed responses to call lights, leading to resident dissatisfaction and compromised care.
Failure to Ensure Dignity and Timely Care Due to Staff Conduct and Insufficient Staffing
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were treated with dignity and had their needs met in a timely manner, as required by resident rights regulations. Multiple residents reported that their care needs were only met about half the time, with specific complaints about insufficient staffing, long wait times for assistance, and lack of responsiveness to call lights. Residents described being left on the toilet for extended periods, missing scheduled showers due to staff shortages, and not receiving help with meal setup. One resident, who used a writing board for communication, reported that an aide told them to "do it on your own" when they requested help. During a resident council meeting, all residents present unanimously stated that they did not receive care when needed, citing frequent understaffing and inconsistent aide performance. Specific complaints were made about a particular aide, who was described as rushed, rude, and dismissive. Residents recounted instances where the aide snapped at them, made insensitive remarks, and failed to provide timely incontinence care. Two residents reported that their call light was left unanswered for extended periods, resulting in one resident being unable to access a bedpan in time. The aide's behavior was characterized as lacking in customer service, with residents feeling talked down to and experiencing diminished self-worth. These findings were based on direct resident interviews, observations, and review of facility records.
Deficient Shower Room Maintenance and Cleanliness
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in its shower rooms, as required by federal regulations. The only operational shower room in the building, located on the 100-Hall, had black residue on the wall tiles and caulking, with the residue appearing to be under the caulking and grout. Additionally, there was an area behind the shower curtain with approximately 10 inches of chipped-off tiles, exposing chipped drywall and sharp tile edges, all with visible black residue. The 200-Hall shower room was not in use, as the tub had been removed, and the shower was non-functioning. Interviews with facility staff confirmed awareness of the issues, with the Administrator providing repair quotes for both shower rooms and Maintenance staff indicating that repairs for the 100-Hall shower were scheduled to be completed within 30 days. The 200-Hall shower had a repair quote from several months prior, but repairs had not yet been initiated, as the plan was to address the 100-Hall shower first. These conditions resulted in a failure to provide a sanitary, orderly, and comfortable environment for residents requiring hygiene services.
Failure to Follow Care Plans for ADL and Wound Care
Penalty
Summary
Surveyors identified that the facility failed to follow comprehensive care plans for activities of daily living (ADL) and wound care for three residents. For one resident with Alzheimer's disease, anxiety, and depression, the care plan required staff assistance with bathing and showers twice weekly. However, documentation showed that over a 30-day period, the resident received only one shower and no bed baths, despite the care plan's requirements. There were also insufficient interventions documented for instances when the resident refused showers, and progress notes only sporadically recorded refusals. Another resident, newly admitted with a right toe amputation and a lack of self-care, was observed to have poor hygiene, including greasy hair, facial hair growth, and body odor. The care plan specified showers or bed baths twice weekly, but records indicated only one shower was provided in 14 days, with no documentation of refusals. Observations and interviews confirmed the resident's unkempt appearance and dissatisfaction with the frequency of personal care provided. A third resident, who had recently undergone back surgery, was observed with a surgical dressing that had not been changed as scheduled. The care plan required daily dressing changes, but the resident reported the dressing was not changed on the previous day due to a scheduled leave for a therapy evaluation. The nurse on duty stated that the dressing change was missed because the resident left before it could be completed, and the DON confirmed that dressing changes should be completed as ordered or by the next shift. Documentation inconsistencies were noted regarding whether the dressing change was performed as required.
Failure to Provide Scheduled ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care, specifically personal hygiene and showers, for five dependent residents. Observations and interviews revealed that residents often did not receive scheduled showers or bed baths, resulting in poor hygiene, greasy hair, body odor, and unshaven appearances. Documentation showed that some residents received only one shower in a 14- or 30-day period, with no evidence of bed baths being provided as alternatives. In several cases, there was no documentation of resident refusals for showers or baths, and care plans lacked interventions for refusals or alternative hygiene measures. The deficiency was further compounded by facility infrastructure issues, as only one shower was available for 48 residents due to the removal of a tub in one shower room, which was being used for storage. This limited access to bathing facilities made it difficult to meet the scheduled shower frequency for all residents. Residents expressed dissatisfaction and emotional distress due to missed showers, with some reporting feelings of neglect and sadness. Medical records indicated that the affected residents had significant self-care deficits due to conditions such as Alzheimer's disease, recent amputation, stroke, muscle weakness, Parkinson's disease, and obesity. Despite these needs, care plans did not address the lack of hygiene care or provide strategies for managing refusals. Observations confirmed ongoing issues with personal hygiene, including greasy hair, unshaven faces, and skin irritation, with no evidence of appropriate interventions being implemented.
Failure to Complete Daily Dressing Change as Ordered
Penalty
Summary
A deficiency occurred when a resident with a post-surgical lower back incision did not receive a dressing change as ordered. Observation revealed that the dressing on the resident's back was dated two days prior, despite orders for daily dressing changes. The resident confirmed that dressing changes were supposed to occur every day and noted that he left the facility for a physical therapy home evaluation the previous day, but not until after 11:00 AM. Interview with the RN on duty indicated that she did not perform the dressing change before the resident left, and she cited frequent new admissions and discharges as factors affecting her ability to complete treatments. Review of the Treatment Administration Record showed that the night shift nurse had documented the dressing change as completed, but the physical observation contradicted this, showing the dressing had not been changed since two days prior. The DON confirmed that dressing changes should be completed as ordered and, if missed by one shift, should be done by the next.
Failure to Implement Care-Plan Interventions Leads to New Skin Breakdown
Penalty
Summary
A resident with a history of stroke, aphasia, and hemiplegia, who was totally dependent on staff for all activities of daily living and had severely impaired cognition, was identified as being at very high risk for pressure-related skin injuries based on a Braden Scale score of 8. Despite care plan interventions that included regular repositioning and the use of assistive devices to minimize skin breakdown, the resident was repeatedly observed resting in bed without positioning devices under their left arm. Multiple observations noted a strong odor in the room and under the resident's left breast, where open areas of skin breakdown were found. The care plan also required daily observation of skin condition and reporting of abnormalities, but the new skin breakdown under the left breast was not documented in the skin and wound evaluation prior to surveyor discovery. Further review revealed that the resident's left arm was nearly closed over the left breast, with no positioning device in place to aid in pressure reduction, and staff noted the resident sweated excessively. The facility's own skin management guidelines identified excessive perspiration as a risk factor for moisture-associated skin damage, yet these risks were not adequately addressed. The failure to implement care-planned interventions and to document and report new skin breakdown resulted in the development of multiple open areas under the resident's left breast, indicating a lack of adherence to professional standards of practice for the prevention and management of pressure ulcers.
Medication Cart Left Unlocked and Unattended in Hallway
Penalty
Summary
A medication cart on the 200 Hall was observed left unlocked and unattended in the hallway, making medications accessible to residents, visitors, and staff. The state surveyor was able to open drawers on the cart while the assigned RN was in a resident's room checking blood sugar and conversing with the resident. The RN acknowledged that the cart was left unlocked unintentionally when questioned by the surveyor. Review of the RN's employee record showed that she had previously received a one-on-one inservice in March 2025 regarding the requirement to keep medication and treatment carts locked at all times when not in use. The facility's policy also states that unlocked medication carts are not to be left unattended. The Director of Nursing confirmed awareness of the incident and reiterated that medication carts should remain locked when the nurse is not present.
Failure to Document Immunization Education and Refusal
Penalty
Summary
The facility failed to provide proper documentation and education regarding immunization refusal for one resident among five reviewed for immunizations. Specifically, the resident had refused the RSV vaccine in December 2024, but there was no signed refusal form or progress note in the medical record to indicate that education about the vaccine's benefits and potential side effects had been provided, nor was there documentation of the refusal itself. The electronic medical record contained a blank vaccine consent form with no refusals or signatures, and the Infection Control Preventionist confirmed that the form was not filled out by staff. Further review of the resident's progress notes from late 2024 through mid-2025 revealed no entries regarding RSV vaccine education or refusal, even after the resident was readmitted from the hospital with a diagnosis of RSV following a respiratory illness. The lack of documentation persisted throughout the resident's stay, indicating that the facility did not follow its own policies and procedures for recording immunization education and refusal, as required by regulation.
Deficiency in Sprinkler System Installation
Penalty
Summary
A deficiency was identified regarding the installation of the sprinkler system. The report notes that nursing homes and hospitals, where required by construction type, must be protected throughout by an approved automatic sprinkler system. The facility did not meet this requirement, as the necessary sprinkler system installation was not in place as specified by the 2012 standards for existing buildings.
Plan Of Correction
Element 1: No residents were identified in this concern. The light fixture in the lobby was moved to accommodate the required distance from the sprinkler head. Completed by 7/24/2025
Failure to Provide Required Number of Basement Exits
Penalty
Summary
Surveyors observed that the facility failed to provide the required number of exits from the basement, as mandated by NFPA 101, sections 19.2.4.1 through 19.2.4.4. During an inspection, it was found that there was only one exit available from the basement, which is occupied by the laundry area (including a linen chute from the first floor), employee break room, maintenance office, boiler room, storage room, electrical room, and employee bathroom/locker room. This observation was confirmed through interviews with the Director of Facilities and the Maintenance & Environmental Services Director at the time of the survey. Approximately 10 occupants could be affected by this deficiency in the event of a fire emergency, as the basement does not meet the requirement for at least two remote and accessible exits from every story and compartment.
Plan Of Correction
Element 1 No residents were identified. Residents do not have access to the basement. Staff are aware of the emergency exit. Element 2 All other areas where residents have access to, have required exits. Element 3 The facility administrator has contracted with the LSC Specialist to conduct a Fire Safety Evaluate System (FSES) survey for a waiver request. The FSES will be completed on 7/18/2025 and forwarded to Life Safety for a waiver request. Element 4 Audit will be completed weekly regarding accessible exits on every story. Results will be reviewed with the Administrator and brought to monthly QAPI for review and recommendations. Administrator is responsible for compliance.
Sprinkler Head Installed Too Close to Light Fixture
Penalty
Summary
Surveyors observed that the facility failed to provide a sprinkler system installed in accordance with NFPA 13 requirements. Specifically, during an inspection, it was found that the sprinkler head located in the main lobby near the front egress door was positioned too close to a light fixture. This proximity was determined to be within a few inches, which does not comply with NFPA 13, 8.3.2.5, Table 8.3.2.5(c), as it could alter the water flow pattern and prevent proper sprinkler protection. These findings were confirmed through interviews with the Director of Facilities and the Maintenance & Environmental Services Director at the time of observation.
Plan Of Correction
Element 2: An audit of the facility determined that 3 additional light fixtures are located too close to the sprinkler heads. Element 3: Electrician is scheduled to move overhead lights to be completed by 7/24/2025. Element 4: EVS Director or designee will audit sprinkler heads weekly to ensure that they are not blocked and provide proper sprinkler protection. Results will be brought to weekly QA for review and recommendations. EVS Director is responsible for compliance.
Failure to Ensure Accessibility of Call Lights and Privacy Curtains
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of several residents by not providing timely responses to call lights, ensuring call lights were within reach, and ensuring privacy curtains were accessible and used. Observations revealed that privacy curtains in rooms 100, 103, 107, 108, and 110 were tucked away out of reach, compromising the residents' privacy. Additionally, a resident was found with their call light placed approximately four feet away on a chair, making it inaccessible. This resident expressed a feeling of neglect, suggesting that the call light was intentionally placed out of reach. Further observations confirmed that privacy curtains remained out of reach in multiple rooms, even after the issue was brought to the attention of the Assistant Director of Nursing (ADON). A Certified Nursing Assistant (CNA) admitted to not pulling the curtain during a personal care task, citing the task's nature as the reason. These actions and inactions resulted in unmet care and privacy needs for the residents involved.
Deficiency in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for four residents, resulting in issues such as long jagged fingernails, missed showers, and an unkempt appearance. Resident #5, who is totally dependent on staff for personal hygiene, missed two scheduled showers within a 30-day period. Resident #21, who requires assistance due to anoxic brain damage and physical limitations, was observed with long, jagged nails and dirty buildup on their palms, despite the care plan indicating the need for hand hygiene and the use of hand protectors. Resident #33, who requires limited assistance with bathing, reported not receiving scheduled showers due to staff availability, missing two showers in a 30-day period. Resident #36, who requires extensive assistance with dressing, was found in their nightgown for three consecutive days, with their call light out of reach, indicating a lack of assistance in dressing and potential neglect in responding to their needs. The facility's policy states that residents should receive care to maintain or improve their ability to carry out ADLs, including grooming and personal hygiene, which was not adhered to in these cases.
Failure to Prevent Pressure Ulcer and Ensure Nutritional Care
Penalty
Summary
The facility failed to prevent the development of a facility-acquired pressure injury and ensure timely nutritional care plans were updated and implemented for a resident. The resident, who was admitted with a diagnosis of pulmonary embolism and type 2 diabetes, developed a deep tissue pressure injury on the left heel a few weeks after admission. The wound nurse noted the injury as a blackened area measuring 2.55 cm by 2.57 cm, and the resident experienced pain during treatment. Despite the resident's alertness and orientation, the facility did not have any wounds indicated in the admission diagnosis, and the care plan was only revised on the day the state survey began. The resident experienced a significant weight loss of 10 pounds, or 9.13%, within approximately three weeks of admission. The facility's dietary management failed to consistently provide the prescribed nutritional interventions, such as protein shakes and cottage cheese, which were intended to aid in wound healing. The resident and their significant other reported inconsistencies in receiving the prescribed nutritional supplements and meals that were not aligned with the resident's dietary needs for diabetes and wound healing. Interviews with the dietary manager and registered dietician revealed a lack of awareness and follow-up regarding the resident's nutritional needs and preferences. The dietary manager admitted to not being aware of the resident's complaints and the registered dietician acknowledged the need for better monitoring of the resident's protein intake. The facility's wound policy aimed to identify residents at risk for skin alterations and implement specific interventions, but these measures were not effectively executed for the resident in question.
Failure to Apply Palm Protectors for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident to maintain or improve their range of motion, specifically by not applying bilateral palm protectors as required. Resident #21, who was admitted on 8/14/2020, was observed multiple times over two days without the necessary palm protectors on their hands, despite having contracted hands. The resident's care plan, as noted in the Kardex, specified that bilateral hand protectors should be worn during the day after hand hygiene and removed at night with skin checks for redness. The Therapy Director (TD) confirmed that Resident #21 had been on therapy with a discharge recommendation for palm protectors to be worn during the day. During an observation with the TD, the palm protectors were found in the resident's nightstand drawer, not in use. The TD cleaned the resident's hands, performed nail care, and applied the palm protectors. An instruction photo in the resident's closet showed how the palm protectors should be placed, and the TD stated that staff had been educated on their application.
Improper Storage of Narcotics During Medication Administration
Penalty
Summary
The facility failed to properly store narcotics for a resident during a medication administration task. On the morning of July 16, Nurse B prepared morning medications for a resident, including a Norco 5/325 tablet and a Pregabalin 150 mg tablet, and placed them in a clear medication cup. When the resident requested to take the medications later, Nurse B capped the cup, wrote the room number on it, and placed it in the top drawer of the medication cart instead of following proper storage procedures for narcotics. Later, Nurse B retrieved the medication cup from the drawer, counted the medications, and administered them to the resident. When questioned about the counting, Nurse B explained it was because the medications had been placed in the drawer. The Director of Nursing was informed of the incident and acknowledged that Nurse B should not have stored the narcotics in the drawer. The facility's Controlled Substances Policy states that medications not given should be destroyed and not returned to the container, indicating a breach of protocol in this instance.
Failure to Honor Dietary Preferences and Provide Palatable Meals
Penalty
Summary
The facility failed to honor a resident's food preferences and provide palatable meals, leading to significant weight loss and potential health risks. The resident, who was on a Controlled Carbohydrate Diet and No Added Salt diet, reported dissatisfaction with the meals provided, which were high in carbohydrates and sugar, contrary to her dietary needs for managing Type 2 Diabetes. Despite her preferences being documented, the meals served did not align with her dietary restrictions or personal likes, such as the inclusion of white bread and sugar cookies, and the absence of requested items like strawberries and cottage cheese. The resident's significant other corroborated her complaints, noting that he often had to bring fresh fruits from home because the facility did not provide them. During a meal observation, the resident's lunch tray contained items she disliked and were inappropriate for her dietary needs, such as a thick slice of white bread and a sugar cookie. The resident expressed frustration over the facility's failure to follow her documented preferences, which contributed to her reduced food intake and subsequent weight loss. Interviews with the Dietary Manager and Registered Dietician revealed a lack of awareness regarding the resident's unmet preferences and inconsistent provision of protein drinks. The facility's policies on therapeutic diets and food preferences were not effectively implemented, as evidenced by the resident's documented weight loss of 10 pounds over three weeks. The care plan included interventions to monitor for signs of malnutrition and honor food preferences, but these were not adequately followed, resulting in the deficiency.
Deficiency in Hospice Service Documentation and Communication
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in a lack of progress notes and assessments in the resident's medical record. During an observation, the resident was found grimacing and uncomfortable, and although the resident was under hospice care, the unit nurse had not notified the hospice agency about the resident's symptoms of nausea and vomiting. The hospice services binder for the resident lacked progress notes, a facility communication log, and follow-up documentation after a certain date, indicating ineffective communication and collaboration between the facility and hospice services. The hospice services binder contained minimal documentation and lacked details of services provided to the resident. The hospice staff's visits were not clearly documented, and there was a delay in scanning hospice progress notes into the facility's electronic medical record (EMR). The Director of Nursing acknowledged the communication gap and the delay in documentation submission. The hospice RN confirmed that the information in the resident's binder was outdated and that progress notes were sent via fax to the facility, which then scanned them into the EMR. Additionally, there were discrepancies in the administration of Morphine Sulfate, with doses given at intervals shorter than prescribed. The medication administration record showed multiple instances where the medication was administered less than the required six-hour interval. There were no noted changes in the prescribed order from any medical personnel regarding the dosages and frequency of administering the medication. The facility's policy specified that it is the hospice's responsibility to manage the resident's care related to the terminal illness, but the lack of proper documentation and communication led to potential unmet needs and suffering for the resident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly implement Enhanced Barrier Precautions (EBP) in several rooms, leading to potential cross-contamination and spread of infections. On multiple occasions, staff members were observed not wearing the required Personal Protective Equipment (PPE) in EBP rooms. For instance, a nurse was seen sitting on a resident's bed without any PPE, and a CNA was caring for a resident who had an incontinent episode while only wearing gloves, without a gown to protect their uniform. These actions were contrary to the physician's order for enhanced barrier precautions, which required both gloves and gowns prior to high-contact care activities. Additionally, a housekeeper was observed cleaning the toilet and floor in an EBP room without wearing a gown, which is necessary to prevent contamination of their uniform. The facility's policy, based on CDC recommendations, mandates the use of gowns and gloves to protect residents and staff from hard-to-treat infections. Despite the presence of signs indicating the need for enhanced precautions, staff failed to adhere to these guidelines, as evidenced by the observations and record reviews conducted during the survey.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Bay City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bay Shores Senior Care And Rehab Center | 3.1 mi | ★★★★★ | 13 | 0 |
| Bay County Medical Care Facility | 4 mi | ★★★★★ | 2 | 0 |
| Carriage House Nursing And Rehabilitation | 4.6 mi | ★★★★★ | 1 | 0 |
| Caretel Inns Of Tri-cities | 5.1 mi | ★★★★★ | 3 | 0 |
| Huron Woods Nursing Center | 9.4 mi | ★★★★★ | 15 | 0 |
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