Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Northampton Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
MDS assessments were inaccurately coded for three residents. One resident with ESRD and COPD had orders for O2 and dialysis, but the MDS did not code either service. Another resident with diabetes received insulin glargine as ordered, but the MDS did not code hypoglycemic medication use. A third resident with Alzheimer’s disease had hospice services and a hospice care plan, but the MDS coded the resident as not receiving hospice care.
A nurse aide failed to follow EBP PPE requirements when providing dressing care to a resident with an indwelling urinary catheter. The aide wore gloves but did not wear a gown during high-contact ADL care, despite EBP signage and PPE supplies being posted at the room entrance. The aide stated she had not read the sign before providing care, and the IP, DON, and Administrator all confirmed a gown and gloves were required.
Surveyors found that the facility did not maintain and post a current daily nurse staffing sheet at the main entrance, as the sheet displayed was several days out of date and did not reflect the current census or staffing. The Scheduler reported preparing and handing off completed staffing sheets to the ADON, who placed them in a staffing binder at the nurse's station with the expectation that nursing staff would update and post them. The DON and Administrator confirmed that the charge nurse was responsible for ensuring the daily nurse staffing sheet was updated and visibly posted for residents and visitors on weekends, but this did not occur on one of the reviewed days.
The facility was found to have improper food storage and handling practices in the kitchen. Opened food items in two refrigerators were not dated, an expired box of taco shells was found in the dry goods storage room, and a plastic measuring cup was left in a sugar bin, risking cross-contamination. The Dietary Manager acknowledged these oversights and confirmed her responsibility for proper food storage.
A facility failed to hold a care plan meeting for a resident with moderate cognitive impairment, neglecting to invite the resident and their RP to participate. The Social Worker missed the resident's name on the list provided by the MDS Nurse, resulting in no meeting being scheduled. The Administrator confirmed the Social Worker was responsible for this task.
The facility failed to update care plans for two residents, one with an indwelling urinary catheter and another using side rails for mobility. Despite physician orders and daily use, the care plans were not revised due to unclear responsibilities and communication breakdowns among staff, as revealed in interviews with the Nurse Supervisor, Resource Nurse, MDS Nurse, and DON.
A resident with severe cognitive impairment and a stroke diagnosis had an indwelling urinary catheter placed without comprehensive physician orders for its management. The facility failed to document specific orders for catheter size, fluid amount, and change schedules. Interviews revealed confusion among staff about who was responsible for entering these orders, leading to the oversight.
The facility failed to provide an arbitration agreement that explicitly granted residents or their representatives the right to rescind the agreement within 30 days of signing it. This deficiency was identified for three residents. Interviews revealed that the Admission Director was unaware of the requirements for the arbitration agreement, and the Administrator was new to the facility and unfamiliar with the agreement.
A facility failed to implement its infection prevention and control program when a nurse aide did not perform hand hygiene between resident interactions and two staff members did not wear isolation gowns during wound care for a resident on Enhanced Barrier Precautions. Despite available PPE supplies and prior education, the staff did not adhere to the facility's policies, leading to deficiencies in infection control.
MDS assessments were inaccurately coded for oxygen, dialysis, insulin, and hospice services
Penalty
Summary
The facility failed to accurately code the MDS assessment for three residents in the areas of supplemental oxygen and dialysis, hypoglycemic medication use, and hospice services. Resident #39 was admitted with diagnoses including end stage renal disease with dependence on dialysis and COPD, and had physician orders for oxygen at 3 LPM via nasal cannula to keep oxygen saturation greater than 90% every shift and dialysis on Monday, Wednesday, and Friday. However, the quarterly MDS assessment did not code the resident for supplemental oxygen or dialysis, and the MDS Nurse stated she was aware of the resident's oxygen use and dialysis but miscoded the assessment. Resident #9 was admitted with diabetes and long-term insulin use, had an order for insulin glargine 80 units at bedtime, and received the insulin as ordered per the January 2026 MAR, but the quarterly MDS did not code the use of a hypoglycemic medication. Resident #29 was admitted with Alzheimer's disease, heart disease, and diabetes, had an order to continue hospice services, and had a hospice care plan initiated with interventions including spiritual care consult, notification of the physician for significant changes, and medication per physician orders, but the admission MDS coded the resident as not receiving hospice care. In interviews, the MDS Nurse stated she mistakenly coded the hospice status, and the Administrator stated the MDS should accurately reflect the resident at the time of assessment.
Failure to Use Required PPE During EBP Care
Penalty
Summary
The facility failed to implement its infection prevention and control program when a nurse aide did not use the required PPE during ADL care for a resident on Enhanced Barrier Precautions. The facility’s IPCP, revised April 2023, stated it was intended to maintain a safe, sanitary, and comfortable environment and prevent the development and transmission of diseases and infections. The EBP policy, also revised 4/01/23, required gowns and gloves for high-contact resident care activities, including dressing and transferring, and applied to residents with an indwelling medical device such as an indwelling catheter. During observation, Resident #2 had EBP signage posted at the room entrance and PPE supplies, including disposable gowns and gloves, were available on the door. A nurse aide provided dressing care while wearing gloves but did not wear a gown. The nurse aide assisted the resident with putting on a shirt and pants, turned the resident from side to side to complete dressing, and moved the indwelling urinary catheter bag onto the bed between the resident’s legs without a disposable gown in place. The nurse aide then removed gloves and performed hand hygiene. When interviewed immediately afterward, the nurse aide stated she was not aware she needed to wear a gown and confirmed she had not read the sign before providing care. The IP, DON, and Administrator all stated the nurse aide should have worn a gown and gloves for the care provided.
Failure to Maintain and Post Current Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post an updated daily nurse staffing sheet for residents and visitors for one of four days reviewed during the survey period. On a Sunday during the initial tour at 9:40 AM, surveyors observed that the daily nurse staffing sheet posted near the facility entrance was dated from the prior Thursday and had not been updated to reflect the current date, census, or staffing information. No resident-specific information, medical history, or clinical conditions were mentioned in relation to this deficiency. Interviews with staff revealed that the Scheduler prepared daily nurse staffing sheets and typically placed them in a binder at the nurses' station on Fridays for weekend use. The Scheduler stated she had last worked on Thursday and had given the completed staffing sheets for the following three days to the Assistant Director of Nursing (ADON), who reported placing them in a green staffing binder at the nurse's station and relying on nurses to ensure they were current and posted. The DON stated that the charge nurse was responsible for ensuring the daily nurse staffing sheets were posted, and confirmed that the nurse interviewed was the charge nurse that weekend. The Administrator stated the Scheduler was responsible for completing the sheets Monday through Friday, and nurses were responsible for posting them on weekends, confirming that the charge nurse should have updated and posted the current staffing information where it was clearly visible to residents and visitors.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
The facility failed to adhere to proper food storage and handling protocols, as observed during a survey. In the kitchen, two refrigerators were found to contain opened food items that were not dated, specifically a plastic bag of shredded lettuce in the walk-in refrigerator and a large box of grated parmesan cheese in the free-standing refrigerator. Additionally, the dry goods storage room contained a box of hard taco shells that had expired. Furthermore, a plastic measuring cup was found resting inside a large sugar storage bin, which posed a risk of cross-contamination. The Dietary Manager confirmed these findings during the survey and acknowledged the oversight. She admitted that all items placed in the refrigerator should be dated when opened and that the measuring cup should not be left inside the sugar bin without being washed. The Dietary Manager also stated that she missed checking the expiration date on the hard taco shells. The Administrator confirmed that the Dietary Manager was responsible for ensuring that food items were properly dated, labeled, and stored in the kitchen.
Failure to Include Resident and RP in Care Planning
Penalty
Summary
The facility failed to hold a care plan meeting and invite a resident and their Responsible Party (RP) to participate in the care planning process. The resident, who was admitted to the facility and had moderate cognitive impairment, was not included in a care plan meeting after an initial meeting held via telephone. The electronic medical record lacked documentation of any subsequent care plan meetings or invitations to the resident or RP. Interviews with facility staff revealed a breakdown in communication and responsibility. The Social Worker, who was tasked with scheduling care plan meetings, did not schedule a meeting for the resident because they missed the resident's name on the list provided by the MDS Nurse. The MDS Nurse confirmed that the resident was on the list for a care plan meeting, but the Social Worker failed to coordinate it. The Administrator confirmed that the Social Worker was responsible for scheduling the meeting, indicating a lapse in the facility's care planning process.
Failure to Revise Care Plans for Indwelling Catheter and Side Rails
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care management. Resident #36, who has severe cognitive impairment and was always incontinent of bladder, was admitted with an indwelling urinary catheter placed on a physician's order due to decreased urine output. Despite the catheter being in place, the care plan was not updated to reflect this change. Interviews with the Nurse Supervisor, Resource Nurse, MDS Nurse, and Director of Nursing revealed a lack of clarity and communication regarding responsibility for updating the care plan, resulting in the omission being overlooked during clinical meetings. Similarly, Resident #67, who has moderate cognitive impairment and requires assistance for mobility, was using side rails for enhanced independence. However, the care plan did not include the use of side rails, despite their daily use since admission. Interviews with the Resource Nurse, MDS Nurse, and Director of Nursing indicated that the responsibility for updating the care plan was unclear, and the omission was not identified during clinical meetings. Both cases highlight a breakdown in communication and responsibility among staff members, leading to the failure to update care plans appropriately.
Failure to Obtain Comprehensive Physician Orders for Catheter Management
Penalty
Summary
The facility failed to obtain comprehensive physician orders for the management of an indwelling urinary catheter for a resident who was admitted with a diagnosis of stroke and severe cognitive impairment. The resident had a physician order to place an indwelling urinary catheter due to decreased output, but the electronic medical record lacked specific orders regarding the catheter size, the amount of fluid to anchor the catheter, the time frame for changing the catheter, and the catheter bag. The nursing progress note indicated that an 18 French catheter with 5 cc of fluid was used, but no further management orders were documented. Interviews with the Nurse Supervisor, Resource Nurse, and Director of Nursing revealed a lack of clarity and communication regarding the responsibility for entering all necessary standing orders for the catheter's management. The Nurse Supervisor believed the Resource Nurse would enter additional orders, while the Resource Nurse stated it was the Nurse Supervisor's responsibility. The Director of Nursing acknowledged the oversight and stated that the nurse who obtained the physician order should have implemented all required standing orders. The Administrator confirmed that the nurse who obtained the order was responsible for entering associated orders.
Failure to Include Rescission Rights in Arbitration Agreement
Penalty
Summary
The facility failed to provide an arbitration agreement that explicitly granted residents or their representatives the right to rescind the agreement within 30 days of signing it. This deficiency was identified for three residents. The arbitration agreement, dated 7/15/24, stated that the agreement could be rescinded by written notice within thirty days, but did not explicitly mention the right to rescind. Resident #63's representative signed the agreement on 10/29/24, Resident #76 signed on 7/30/24, and Resident #33's representative signed on 9/18/24. Interviews with the Admission Director and the Administrator revealed a lack of awareness regarding the requirements for the arbitration agreement, with the Admission Director stating she was provided with the document by the facility and had no knowledge of what was required to be included, and the Administrator being new to the facility and unfamiliar with the agreement.
Infection Control and PPE Policy Breaches
Penalty
Summary
The facility failed to implement its infection prevention and control program, as evidenced by the actions of Nurse Aide #1, who did not perform hand hygiene before donning and after removing gloves in four resident rooms. During an observation, Nurse Aide #1 was seen leaving a resident's room, retrieving a clothing protector, and returning to the room without performing hand hygiene. This pattern continued as she moved between resident rooms and handled meal trays without washing her hands. In an interview, Nurse Aide #1 acknowledged the lapse, attributing it to being focused on distributing meal trays. Additionally, the facility did not adhere to its Personal Protective Equipment (PPE) policy during wound care for a resident on Enhanced Barrier Precautions (EBP). The Wound Treatment Nurse and Nurse Aide #2 failed to wear isolation gowns while performing wound care, despite signage indicating the requirement for gowns and gloves. Both staff members performed hand hygiene and donned gloves but neglected to wear gowns, which was a breach of the EBP policy. The Wound Treatment Nurse admitted to being nervous and forgetting to don the gown, while Nurse Aide #2 acknowledged the oversight after the procedure. Interviews with the Director of Nursing and the Administrator confirmed that staff were expected to follow hand hygiene and PPE protocols. The Infection Preventionist also noted that both the Wound Treatment Nurse and Nurse Aide #2 had previously received education on EBP requirements. Despite the availability of PPE supplies, the staff's failure to adhere to the infection control policies resulted in deficiencies in the facility's infection prevention and control program.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rich Square Nursing & Rehabilitation Center | 9.5 mi | ★★★★★ | 9 | 0 |
| Liberty Commons Nursing And Rehabilitation Center | 12.3 mi | ★★★★★ | 1 | 0 |
| Signature Healthcare Of Roanoke Rapids | 15.5 mi | ★★★★★ | 10 | 0 |
| Bryan Health And Rehab | 17.5 mi | ★★★★★ | 0 | 0 |
| Scotland Manor Health And Rehabilitation Center | 17.8 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.