Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Hampton Woods Nursing Center, Inc during CMS and state inspections, most recent first.
The facility failed to prevent tampering with and possible diversion of liquid morphine prescribed for three hospice residents with terminal conditions and cognitive impairment. Over several months, these residents had PRN morphine orders for pain and dyspnea, but records showed little to no documented administration and daily pain scores of zero. Multiple sealed morphine bottles assigned to two residents were later found with wet or smeared labels, reduced volumes compared to what should have been present, and, upon pharmacist inspection, puncture holes in the bottoms of the bottles. Some nurses signed off controlled substance counts as correct and did not report discrepancies, and law enforcement subsequently confirmed the bottles had been tampered with and opened an investigation.
A resident with multiple chronic conditions who required staff assistance for medication administration was given another resident’s medications when an RN failed to verify identity before a morning med pass. The RN entered the room, stated she had the resident’s medicine, and administered several incorrect drugs, only questioning the situation when attempting to give a Lovenox injection and the resident reported never having received shots there. The resident later confirmed receiving the wrong medications from an unfamiliar nurse and reported the incident to family, and the DON verified that the wrong medications had been administered, contrary to facility policy requiring identity verification prior to med administration.
A facility failed to promptly notify hospice of a resident's fall and subsequent change in condition, resulting in an unwanted ED transfer. The resident, who was severely cognitively impaired and receiving hospice services, was found on the floor without initial injuries. Despite instructions to notify hospice in such events, the facility delayed communication, leading to a late notification after the resident was transferred to the ED for a hip fracture.
The facility did not ensure residents were offered snacks when there was more than 14 hours between dinner and breakfast. Residents reported feeling hungry at night, and staff confirmed snacks were only provided upon request. The dietitian acknowledged the extended meal gap and logistical challenges but confirmed residents had not agreed to this schedule.
The facility failed to accurately complete the TB Risk Assessment, affecting all 60 residents. The initial assessment was outdated, and the updated version was incorrectly dated. The DON completed the assessment on October 7, 2024, but mistakenly recorded the date as January 2024.
A facility failed to feed a resident in a dignified manner, violating their rights. The resident, with severe cognitive impairment and multiple medical conditions, required meal assistance. An STNA was observed standing while feeding the resident, contrary to facility policy requiring staff to sit at the same level as residents during feeding. The STNA cited being busy as the reason for standing, and a dietitian confirmed the policy.
The facility failed to properly complete DNR forms for two residents, affecting their rights to have their advance directives accurately implemented. One resident's form lacked the necessary indication of whether the DNR protocol should be applied immediately or at the point of arrest, despite having a DNR order. The same issue was found with another resident's form, requiring an LPN to check electronic records for clarification. Both residents had complex medical histories and required varying levels of assistance.
The facility failed to notify the physician of significant health changes in two residents. One resident with diabetes had multiple instances of elevated blood sugar levels above 300, and another resident experienced significant weight gains. Despite physician orders to notify them of these changes, there was no documentation of such notifications, violating the facility's policy on condition change reporting.
A facility failed to submit a resident's MDS 3.0 assessment to CMS within the required timeframe. The assessment, completed over 14 days late, was identified through record review and staff interviews. The resident had multiple diagnoses, including multiple sclerosis and hypertension. The facility's policy mandates timely submission of assessments.
The facility failed to include advanced directives and specific medical needs in the care plans of two residents. One resident with multiple diagnoses and a DNR-CCA order did not have these reflected in their care plan, and another resident on a fluid restriction due to SIADH also had omissions in their care plan. Staff interviews confirmed these deficiencies, which were not in line with the facility's policy.
A resident's potassium medication was left unsecured at the bedside due to an LPN being distracted by a commotion and a resident's request. The resident, with multiple health conditions, confirmed the pill was theirs. The facility's policy requires medications to be administered safely by licensed personnel, which was not followed.
A facility failed to track and manage fluid intake for a resident with a physician-ordered fluid restriction of 1200 ml daily. Despite the resident's conditions like COPD and SIADH, there was no documentation on fluid dispersion, and the resident received inappropriate items like Jello. Staff interviews revealed a lack of communication and understanding of the fluid restriction, with no proper documentation or education provided to the resident.
The facility failed to cover nebulizer masks or pipes for two residents, one with chronic heart failure and another with respiratory failure and COPD. Despite physician orders for nebulizer treatments, the equipment was left uncovered, contrary to facility policy. This was confirmed by RNs during observations.
The facility failed to implement Enhanced Barrier Precautions (EBP) during high-contact care for three residents with indwelling medical devices. Staff did not wear gowns as required, relying on a purple magnet system for EBP indication, which led to oversight. The lack of clear signage contributed to the failure to adhere to EBP protocols.
Tampering and Possible Diversion of Hospice Residents’ Liquid Morphine
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from tampering with and possible diversion of their prescribed liquid morphine, a controlled substance. Three hospice residents with terminal diagnoses and cognitive impairment had active PRN morphine orders for pain and/or shortness of breath. Record reviews for these residents showed that, over a multi‑month period, they had either no or minimal documented morphine administration despite having orders in place and care plans that included assessing pain and administering pain medication as ordered. Daily pain assessments for all three residents consistently documented pain scores of zero, and the Minimum Data Set assessments reflected no recent use of pain medications for two of the residents and only one PRN dose for the third. The self‑reported incident and pharmacy documentation showed that multiple sealed bottles of morphine, assigned to two of the residents, were found with irregularities in appearance and volume. On one evening, nursing staff observed a morphine bottle with a label that appeared wet and smeared, although the bottle and packaging were dry and the controlled substance count was documented as correct. By the following evening, the same sealed bottle showed a 2–3 mL discrepancy between the amount that should have been present and the amount actually in the bottle, yet the oncoming and off‑going RNs signed the controlled substance count as correct and did not report the discrepancy. Subsequent counts by other nurses identified that the bottle and packaging were wet, the label was smeared, and there remained a 2–3 mL discrepancy between the recorded 15 mL and the 12 mL present in the sealed bottle. Further review revealed another unopened morphine bottle that was wet and contained only 12 mL instead of the full 15 mL, and later a separate bottle was found with a 1 mL discrepancy. The pharmacist’s on‑site review identified single puncture holes on the bottoms of two morphine bottles, confirming tampering. Police took three bottles as evidence and stated they were definitely tampered with, and the incident was described as an ongoing investigation. The facility’s abuse, neglect, and misappropriation policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, and the tampered morphine bottles were documented as belonging to two of the hospice residents.
Failure to Verify Resident Identity Resulting in Wrong Medication Administration
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when a registered nurse administered another resident’s medications without properly verifying identity. The resident, who had diagnoses including hypertension, hypothyroidism, hyperlipidemia, anemia, history of falls, and a history of right femur fracture, required staff assistance with medication administration and had intact cognition. During a morning medication pass, the nurse entered the resident’s room, stated, “I have your medicine,” and proceeded to administer multiple medications—Amlodipine, Bupropion, Lisinopril, Paxil, and Prednisone—that were not prescribed for this resident. The nurse later documented that she had not verified she had the correct resident before administering the medications. The error was discovered when the nurse attempted to administer a Lovenox injection, and the resident questioned this, stating she had never received a shot at the facility. At that point, the nurse left the room, checked the medications, and realized she had been in the wrong room and had given the wrong medications. The resident later confirmed in an interview that she had been given medications by a nurse she had never seen before and that she questioned the nurse when a shot was attempted. The resident’s family also reported that the resident had called them at the time to report she had been given the wrong medications. The current DON confirmed that the nurse had administered the wrong medications, and review of the facility’s medication administration policy showed that staff were required to verify resident identity before giving medications, which did not occur in this incident.
Failure to Timely Notify Hospice of Resident's Condition Change
Penalty
Summary
The facility failed to notify the hospice provider in a timely manner regarding a change in condition for a resident, leading to an unwanted transfer to the Emergency Department (ED). The resident, who was receiving hospice services, was severely cognitively impaired and required varying levels of assistance for daily activities. The hospice nurse had instructed the facility to contact hospice in the event of a fall. However, after the resident was found on the floor with no initial injuries, the facility notified the resident's daughter and physician but did not inform hospice immediately. Later, the resident experienced pain in her left hip, prompting a physician-ordered transfer to the ED, where she was diagnosed with a hip fracture. The family had previously expressed a desire for the resident not to be sent to the ED for any reason. Hospice was only informed of the fall, change in condition, and ED transfer several hours after the incident. Interviews with the Director of Nursing and the Hospice Executive Director confirmed the delay in notification, which was a requirement for the hospice care plan.
Failure to Provide Snacks Between Meals
Penalty
Summary
The facility failed to ensure that residents were offered a snack when there was more than 14 hours between dinner and breakfast, which is a requirement to meet residents' nutritional needs. Observations and interviews revealed that residents were not automatically provided with snacks during this extended period, and snacks were only available upon request. This practice affected all residents except one who was identified as receiving nothing by mouth. Interviews with residents indicated that they experienced hunger at night, and staff did not proactively offer snacks. The facility's meal schedule showed a 15-hour gap between dinner and breakfast, which was confirmed by the dietitian. The dietitian acknowledged the logistical challenges of feeding all units within the required timeframe but confirmed that residents had not agreed to a meal schedule exceeding 14 hours. Staff interviews consistently indicated that snacks were provided only if residents requested them, rather than being offered proactively. This deficiency had the potential to impact the nutritional well-being of the residents.
Inaccurate TB Risk Assessment Completion
Penalty
Summary
The facility failed to ensure the Tuberculosis (TB) Risk Assessment was completed accurately, which had the potential to affect all 60 residents residing in the facility. The initial TB Risk Assessment was completed in January 2023. On October 8, 2024, during a survey, the Administrator was informed that the TB Risk Assessment was outdated and was asked to provide an updated version. The updated TB Risk Assessment provided had a completion date of January 2024. An interview with the Director of Nursing (DON) revealed that the updated TB Risk Assessment was actually completed on October 7, 2024. The DON admitted that upon reviewing the state readiness binder, she discovered the absence of an up-to-date TB Risk Assessment. Consequently, she completed the assessment on October 7, 2024, but mistakenly dated it as January 2024.
Failure to Feed Resident in a Dignified Manner
Penalty
Summary
The facility failed to ensure that a resident was fed in a dignified manner, which is a violation of the resident's rights to a dignified existence and self-determination. The resident in question was admitted with multiple medical diagnoses, including dementia and malnutrition, and required assistance with meals due to severe cognitive impairment. The care plan indicated that the resident was at risk for dehydration and weight loss, necessitating assistance with meals and encouragement to complete meals and fluids daily. During an observation, a State Tested Nurse Aide (STNA) was seen standing while feeding the resident, despite an empty chair being available. The STNA confirmed that she was standing because she was busy attending to other residents. The facility's policy on feeding dependent residents requires staff to sit at the same level as the resident while assisting with feeding. This policy was confirmed by a dietitian, who stated that staff should be sitting while feeding residents.
Deficiency in Completing DNR Forms for Residents
Penalty
Summary
The facility failed to ensure that Do Not Resuscitate (DNR) forms were appropriately filled out for two residents, leading to a deficiency in honoring residents' rights to make decisions about their care. For Resident #262, the medical record indicated a DNR Comfort Care Arrest order dated 09/18/24, but the corresponding DNR form did not have the appropriate box checked to specify whether the DNR protocol should be implemented immediately or only at the point of cardiac or respiratory arrest. This oversight was confirmed during an interview with an LPN, who had to refer to the electronic medical record to determine the resident's DNR status. Resident #262 had multiple medical diagnoses, including acute kidney failure and cognitive impairment, and required varying levels of assistance with daily activities. Similarly, for Resident #15, the DNR Comfort Care form, signed by a Nurse Practitioner on 10/04/24, also lacked the necessary indication of whether the DNR protocol was to be applied immediately or at the point of arrest. This was again confirmed by the same LPN during an interview, who needed to check the electronic medical record for clarification. Resident #15 had a complex medical history, including pulmonary embolism, diabetes with ketoacidosis, and acute ischemic heart disease. The failure to properly complete these forms affected the facility's ability to respect and implement the residents' advance directives accurately.
Failure to Notify Physician of Health Changes
Penalty
Summary
The facility failed to notify the physician of significant changes in residents' health conditions as per the physician's orders. Specifically, Resident #27, who had a history of diabetes, congestive heart failure, chronic kidney disease, and altered mental status, had multiple instances of elevated blood sugar levels exceeding 300, as recorded in the Medication Administration Record (MAR) for August and September 2024. Despite the physician's order to notify them if blood sugar levels were above 300, there was no documentation that the physician or nurse practitioner was informed of these elevated levels. Similarly, Resident #23, who had medical diagnoses including acute kidney failure, type two diabetes mellitus, essential atrial fibrillation, and acute on chronic systolic congestive heart failure, experienced significant weight gains on multiple occasions between July and September 2024. The physician's orders required notification if there was a two-pound weight gain in one day or a three to five-pound weight gain in one week. However, there was no documented evidence that the physician was notified of these weight changes. The facility's policy on Diagnostic Testing/Condition Change Reporting required that the physician, resident, and/or responsible party be notified of unexpected changes in the resident's status, abnormal test results, injuries, or significant treatment alterations. The failure to adhere to this policy and the physician's orders resulted in deficiencies in the care provided to the residents, as the necessary notifications were not made in response to the residents' health changes.
Late Submission of MDS Assessment
Penalty
Summary
The facility failed to ensure the timely submission of a resident's Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS). Specifically, Resident #19's quarterly MDS 3.0 assessment, completed on 08/11/24, was not submitted until 10/08/24, which was more than 14 days late. This deficiency was identified through a review of the resident's medical record, the Internet Quality Improvement and Evaluation System (iQIES) MDS Final Validation Report, and an interview with the MDS Coordinator/LPN. The facility's policy required that all completed assessments be transmitted to the appropriate state agency in a timely manner, in compliance with federal regulations. Resident #19 had been admitted with multiple diagnoses, including multiple sclerosis, depressive disorder, primary osteoarthritis, disorder of thyroid, anxiety disorder, essential hypertension, and atrial fibrillation. Despite the completion of the MDS assessment, the facility did not adhere to the required timeline for submission, as confirmed by the MDS Coordinator/LPN during the interview.
Care Plan Deficiencies for Advanced Directives and Medical Needs
Penalty
Summary
The facility failed to ensure that comprehensive care plans for two residents reflected their advanced directives and specific medical needs. Resident #262, who was admitted with multiple medical diagnoses including acute kidney failure and cognitive impairment, had a physician's order for a Do Not Resuscitate Comfort Care Arrest (DNR-CCA) and an indwelling urinary catheter. However, the care plan for Resident #262 did not include these critical elements. Interviews with facility staff, including an MDS LPN and the Assistant Director of Nursing, confirmed that the care plan did not reflect the resident's code status or the use of the urinary catheter, which was not in line with the facility's policy that care plans should coordinate all necessary care. Similarly, Resident #15, who had a history of pulmonary embolism, diabetes, and other conditions, was on a fluid restriction due to concerns of SIADH and fluid overload. Despite having a physician's order for a 1,200 ml daily fluid restriction and a DNR Comfort Care order, the care plan did not address the fluid restriction or the resident's code status. Interviews with the facility's dietitian and MDS Coordinator confirmed these omissions. The facility's policy stated that care plans should include problems related to diagnosis, physician's orders, and advance directives, but these were not adequately addressed for the residents in question.
Medication Left Unsecured at Bedside
Penalty
Summary
The facility failed to ensure that a resident's medication was not left unsecured at the bedside. During an observation and interview, it was noted that a medicine cup containing a potassium pill was left on the overbed table of a resident. The resident confirmed that the pill was their potassium medication. This incident involved a resident with multiple diagnoses, including a local infection of the skin, atherosclerotic heart disease, type two diabetes, chronic heart failure, chronic kidney disease, permanent atrial fibrillation, and schizoaffective disorder depressive type. The deficiency occurred when an LPN, who was responsible for administering the medication, was distracted by a commotion involving a fallen multivitamin and the resident's request to use the restroom. As a result, the LPN forgot to ensure that the medication was taken by the resident. The facility's policy on medication administration, dated February 2022, requires that all medications be administered safely and appropriately by licensed nursing personnel, which was not adhered to in this instance.
Failure to Track and Manage Fluid Restriction
Penalty
Summary
The facility failed to adequately track and manage fluid intake for a resident with a physician-ordered fluid restriction. The resident, who had a history of conditions such as chronic obstructive pulmonary disease (COPD), hyponatremia, and syndrome of inappropriate antidiuretic hormone (SIADH), was on a 1200 ml daily fluid restriction. Despite this, there was no documentation on how fluids were being dispersed or tracked, and the resident was observed receiving items like Jello, which should not have been provided under the fluid restriction. Interviews with staff revealed a lack of communication and understanding regarding the fluid restriction, with some staff unaware of the specific amounts allowed per meal or the types of food and drink that should be restricted. The facility's policy required a breakdown of fluid distribution to be documented and tracked, but this was not done for the resident in question. The nurse's cart, which was supposed to contain forms detailing fluid restrictions for each resident, lacked any such form for this resident. Additionally, the resident had not been educated on her fluid restriction, only knowing she was allowed one drink per meal and some water with medication, without understanding the specific limits. This lack of documentation and communication led to the deficiency in managing the resident's fluid intake as per the physician's orders.
Failure to Cover Nebulizer Equipment
Penalty
Summary
The facility failed to ensure that nebulizer masks or pipes were covered when not in use for two residents, Resident #16 and Resident #35, out of three reviewed for respiratory care. Resident #16, who was cognitively intact and required moderate assistance for daily activities, had a diagnosis of chronic diastolic heart failure and other lung disorders. Despite having a physician's order for albuterol sulfate inhalation via nebulizer as needed for shortness of breath, the nebulizer pipe was found uncovered on the bedside table. This was confirmed by RN #640, who acknowledged that the pipe should have been covered but could not explain why it was not. Similarly, Resident #35, who was moderately cognitively impaired and required substantial assistance for personal hygiene and mobility, had diagnoses including acute and chronic respiratory failure and COPD. The resident received Ipratropium-Albuterol inhalation solution multiple times a day, yet the nebulizer mask was also found uncovered on the bedside table. RN #640 confirmed this observation, and Admission/Infection Control RN #627 stated that nebulizer components should be rinsed, air-dried, and covered after use. The facility's policy required cleaning and covering of nebulizer parts, but this was not adhered to, leading to the deficiency.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during high-contact resident care, affecting three residents observed for EBP. Resident #164, who had multiple medical conditions including a nephrostomy tube and PEG tube, was not provided with appropriate EBP during care. Registered Nurse #800 and Hospice RN #801 did not wear gowns while providing high-contact care, such as incontinence care and nephrostomy tube dressing change, despite the resident being on EBP. The lack of signage on the resident's door and reliance on a purple magnet as an indicator contributed to the oversight. Similarly, Resident #54, who had an indwelling urinary catheter and was frequently incontinent, did not receive care with the required EBP. Certified Nursing Assistants #649 and #661 provided high-contact care without wearing gowns, as there was no signage to remind them of the EBP requirement. The staff admitted to forgetting to check for the purple magnet, which was the facility's method of indicating EBP status. Resident #262, who had an indwelling urinary catheter and a deep tissue injury, also did not receive care with the necessary EBP. State-tested Nurse Aides #654 and #666 only wore gloves during catheter care, failing to don gowns as required. The absence of clear signage and reliance on a small purple magnet above the door contributed to the staff's failure to adhere to EBP protocols. Interviews with staff confirmed the oversight and the facility's policy of using magnets to discreetly indicate EBP status.
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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 Poland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Center For Rehabilitation At Hampton Woods The | 0 mi | ★★★★★ | 11 | 0 |
| Greenbriar Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Caprice Health Care Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Willow Woods Rehabilitation And Nursing | 2.1 mi | ★★★★★ | 5 | 0 |
| Briarfield Place | 2.1 mi | ★★★★★ | 3 | 0 |
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