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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hampton Health & Rehab Center, Llc during CMS and state inspections, most recent first.
The facility failed to ensure that residents and/or their representatives were given the opportunity to develop advance directives for 12 residents and did not honor an existing advance directive for one resident. The facility's transition to a new electronic health record system was cited as a reason for missing documentation, but the surveyor was unable to locate advance directive information in either the new or previous systems.
The facility failed to provide written transfer notices to four residents and their representatives, as well as notify the LTC Ombudsman, during hospital transfers. The residents, who had various medical conditions, were transferred without proper documentation or notification, as required by facility policy. Staff interviews revealed non-compliance with the notification process.
The facility staff failed to securely store medications and biologicals, as observed in two medication carts and a storage room. An LPN left a Colestipol tablet unattended, and an RN did not label an insulin pen with the required dates. Additionally, expired COVID-19 tests were found in the storage room, contrary to facility policy.
A resident's preference to dine in the dining room was not accommodated due to the dining room being closed on weekends and evenings, as confirmed by staff interviews. Despite the resident being cognitively intact and requiring moderate assistance with eating, the dining room was observed to be unused during breakfast, and the facility's management was unaware of its unavailability. The Dietary Manager claimed it was always open, but the surveyor found otherwise.
A resident with multiple health conditions did not receive a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of their Medicare Part A stay, as required by facility policy. The NOMNC was issued only one day prior, and the facility's social worker could not explain the delay, despite the policy mandating timely notification.
A facility failed to document and communicate necessary information for a resident's transfer to a healthcare institution. The resident, with multiple health conditions, was experiencing confusion and hallucinations. Despite a decision to send the resident to the ER, there was no evidence of a transfer form or communication of essential information to the receiving hospital. This deficiency was confirmed during an interview with corporate staff and discussed with the facility's administration team.
The facility failed to provide bed hold notices to two residents during hospital transfers, as required by policy. One resident, with multiple health conditions, was sent to the ER without a transfer form or bed hold notice. Another resident, also with significant health issues, was transferred twice without receiving the required documentation. These deficiencies were confirmed by corporate staff and discussed with the facility's administration.
The facility staff failed to ensure accurate MDS assessments for two residents, resulting in one resident's discharge being incorrectly coded as to a hospital instead of home, and another resident's discharge MDS assessment not being completed at all. These discrepancies were identified during a surveyor's review and confirmed by staff interviews.
The facility staff did not discard seven containers of unsweetened coconut milk that were past their best by date. A surveyor observed these expired containers in the kitchen's dry storage area, and the Dietary Manager removed them. The issue was discussed with the Administrator, DON, and Clinical Services Manager, but no further information was provided before the exit conference.
An LPN on Unit #1 failed to maintain infection control practices by placing a resident's Breo inhaler in their uniform pocket during medication administration. The LPN had extra items in their hands and chose not to make two trips, leading to this breach. The issue was discussed with facility leadership, but no additional information was provided to the survey team.
The facility staff failed to offer pneumococcal vaccines to three residents upon admission, despite CDC guidelines and facility policy. A resident with cognitive impairment and multiple diagnoses was not offered a PCV15 or PCV20 vaccine, and another resident with a history of diabetes and heart disease was not offered a PCV20 or PPSV23 vaccine. Additionally, a resident with dementia and other conditions was not offered the recommended vaccines. The facility's policy required documentation and timely administration of vaccines, which was not followed.
The facility failed to offer an updated COVID-19 vaccine to a resident and did not provide education or obtain consent for two other residents before administering the vaccine. One resident, who was cognitively intact, was not offered the updated vaccine, while two others did not receive necessary education or consent documentation prior to vaccination.
A resident with a history of stroke and on blood-thinning medications had a critical lab result indicating a life-threatening low hemoglobin level. The result was not addressed by a practitioner until the following day, leading to the resident being sent to the ER for a blood transfusion. The facility staff failed to follow the policy requiring immediate notification of the provider in emergency situations.
The facility staff failed to follow provider orders for two residents, leading to deficiencies in care. One resident did not receive ordered treatments for a surgical wound on multiple occasions, with no evidence of completion. Another resident, who was supposed to be NPO before a procedure, was given breakfast, preventing anesthesia administration. The facility's policy on reviewing orders was not adhered to.
A resident with type 2 diabetes mellitus experienced significant medication errors due to incorrect transcription of insulin orders. The facility staff failed to administer Insulin Lispro according to the hospital discharge sliding scale, resulting in missed doses for blood sugar levels of 137 and 143. Additionally, a dose of Basaglar KwikPen was not administered, with no explanation documented. The error was acknowledged by an LPN and discussed with facility leadership.
A resident with severe cognitive impairment and multiple diagnoses did not receive a provider-ordered Depakote level test. The test was scheduled but not performed, and the absence of results was noted in a pharmacist's report. Facility staff, including the DON and an LPN, confirmed the oversight, and the issue was discussed with administration and regional representatives.
The facility staff failed to maintain complete and accurate clinical records for three residents, leading to deficiencies. A resident's allergy to Hydrocodone was not documented, another resident's record lacked advanced directives despite a DNR order, and a third resident's DDNR form was incomplete. These issues were discussed with the facility's administrative team, but no additional information was provided before the survey's conclusion.
Failure to Ensure and Honor Advance Directives
Penalty
Summary
The facility staff failed to ensure that residents and/or their representatives were given the opportunity to develop an advance directive for 12 out of 22 residents. This deficiency was identified through staff interviews, clinical record reviews, and facility document reviews. The facility's policy, titled 'ADVANCE DIRECTIVES PROTOCOL,' mandates that advance directives be discussed upon admission and reviewed annually. However, for residents such as Resident #3, #5, #29, and others, there was no evidence that the facility staff provided information or facilitated the formulation of advance directives. This lack of documentation and action was acknowledged by the facility's administration during meetings with the survey team. In addition to the failure to provide opportunities for advance directive formulation, the facility staff also failed to honor an existing advance directive for one resident, Resident #23. Despite having a signed and notarized Virginia Advance Directive for Health Care form indicating a preference for no life-prolonging treatments, the resident's clinical records incorrectly listed them as a full code. This discrepancy was not addressed until after the survey team raised concerns, at which point the facility updated the resident's records to reflect their DNR status. The facility's transition to a new electronic health record system was cited as a reason for the missing documentation, as noted in the cases of Residents #4, #16, #62, and others. The administrator admitted that documents had not been fully uploaded to the new system, although access to the previous system was maintained. Despite this, the surveyor was unable to locate advance directive information in either system for several residents. The facility's failure to ensure the proper handling and documentation of advance directives represents a significant oversight in respecting residents' rights and preferences.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide timely written notifications of transfers or discharges to residents and their representatives, as well as to the Office of the State Long-Term Care Ombudsman, for four residents. These deficiencies were identified during a survey, which included staff interviews, facility document reviews, and clinical record reviews. The residents involved had various medical conditions, including cerebral infarction, chronic obstructive pulmonary disease, and depression, and were cognitively intact or moderately impaired. For Resident #26, the facility did not notify the resident or their representative in writing about the transfer to the emergency room due to confusion and hallucinations. The social worker did not notify the Ombudsman of the transfer, and no transfer form was found in the resident's record. Similarly, Resident #129 was transferred to the emergency room for chest pain without written notification to the resident or their representative, and the Ombudsman was not informed. Residents #71 and #72 were also transferred to the hospital on multiple occasions without written notices being provided to them, their representatives, or the Ombudsman. The facility's policy required that discharge notices include the reason for transfer and be documented in the resident's chart, but this was not adhered to. Interviews with staff revealed a lack of compliance with the notification process, and no evidence of written notifications was found in the records for these residents.
Medication and Biological Storage Deficiencies
Penalty
Summary
The facility staff failed to ensure the safe and secure storage of medications and biologicals, as observed in two medication carts and one medication storage room. On Unit 1, a Licensed Practical Nurse (LPN) left a Colestipol tablet unattended on top of a medication cart for approximately nine minutes while attending to a resident in a closed room. The facility's policy clearly states that medications should not be left unattended, yet this protocol was not followed, leading to a potential risk of medication mishandling. Additionally, on Unit 2, a Registered Nurse (RN) failed to label a multi-dose insulin pen with the date of opening or discard date, which is a requirement for medications with shortened expiration dates. Furthermore, in the Unit 1 medication storage room, expired COVID-19 testing cards were found, despite the facility's policy requiring expired items to be stored separately until disposal. These observations indicate lapses in adherence to medication storage and labeling protocols, as well as the management of expired medical supplies.
Dining Room Accessibility Deficiency
Penalty
Summary
The facility staff failed to accommodate the preference of a resident who wished to eat meals in the dining room. The resident, who is cognitively intact with a BIMS score of 15, expressed a desire to leave their room and dine in the dining room. However, the dining room was not available for use during weekends and evenings due to staffing issues, as confirmed by interviews with an LPN and a CNA. The resident's diagnoses include mild protein calorie nutrition and diabetes, and they require partial/moderate assistance with eating. During the survey, it was observed that the dining room was not utilized for breakfast, and housekeeping staff were cleaning the floors. The facility's Dietary Manager claimed the dining room was always open at mealtimes, but the Administrator and DON were unaware of the dining room's unavailability during certain times. Despite the resident's preference and the facility's claim of the dining room being open, the surveyor noted the dining room was not in use, and no further information was provided to address the resident's concern before the exit conference.
Failure to Provide Timely Medicare Non-Coverage Notice
Penalty
Summary
The facility staff failed to provide a Notice of Medicare Non-Coverage (NOMNC) at least two days prior to the end of a Medicare covered Part A stay for one resident. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a range of diagnoses including sepsis, generalized muscle weakness, chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease, and type 2 diabetes mellitus. The last covered day of Medicare Part A services for the resident was April 3, 2024, but the NOMNC was issued and signed by the resident on April 2, 2024, only one day prior to the end of coverage. During an interview, the facility's social worker acknowledged that the NOMNC should have been signed 48 hours prior to the last covered day and was unsure why it was not. The facility's policy, titled Medicare Cut Letter Policy, mandates that residents receive notification of Medicare non-coverage no later than two days before the termination of services. Despite this policy, the required notice was not provided within the stipulated timeframe, and no further information regarding this concern was presented to the survey team before the exit conference.
Failure to Document and Communicate Resident Transfer Information
Penalty
Summary
The facility staff failed to ensure that appropriate information was documented and communicated to the receiving healthcare institution for a resident who was transferred. The resident, who had diagnoses including Type 2 diabetes, chronic obstructive pulmonary disease, protein calorie malnutrition, congestive heart failure, hypertension, depression, and chronic kidney disease, was experiencing confusion and hallucinations. Despite the resident's intact cognition as per the minimum data set assessment, the facility did not provide evidence that the receiving healthcare facility was given adequate information to care for the resident. On the date of the incident, a progress note indicated that the resident was hallucinating and that a decision was made to send the resident to the emergency room. However, there was no documentation of a transfer form or any communication of pertinent information to the receiving hospital, such as contact information for the resident's practitioner, resident representative contact information, advance directives, special instructions, or the resident's comprehensive care plan goals. This deficiency was confirmed during an interview with corporate staff and discussed with the facility's administration team, but no further information was provided to the survey team before the exit conference.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility staff failed to provide evidence of a bed hold notice being given to two residents, leading to a deficiency in compliance with the facility's policy. For one resident, who had diagnoses including Type 2 diabetes, COPD, and chronic kidney disease, there was no documentation of a transfer form or bed hold notice when the resident was sent to the ER due to confusion and hallucinations. The surveyor confirmed with corporate staff that the necessary documentation was not completed, and this issue was discussed with the facility's administration team. Another resident, with diagnoses such as prostate cancer and congestive heart failure, was transferred to the hospital on two occasions without evidence of the bed hold policy being provided to the resident or their representative. The facility's policy requires that a bed hold notice be given at the time of transfer or within 24 hours in emergencies, but no such documentation was found in the resident's records. This concern was also discussed with the facility's administration, but no further information was provided to the survey team before the exit conference.
Inaccurate and Missing MDS Assessments for Discharged Residents
Penalty
Summary
The facility staff failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their discharge status. For one resident, the discharge MDS assessment was incorrectly coded, indicating that the resident was discharged to a short-term general hospital, while the clinical record and staff interview confirmed that the resident was actually discharged home with home health services. This discrepancy was identified during a surveyor's review of the resident's clinical record and was acknowledged by a registered nurse who stated that a correction to the MDS would be made. For another resident, the facility staff failed to complete a discharge MDS assessment altogether. The resident's clinical record indicated that they had been discharged with no return anticipated, yet the MDS assessment was over 120 days old and missing. During an interview, MDS coordinators confirmed the absence of the discharge MDS assessment, attributing the oversight to a software system change earlier in the year. Despite providing a form indicating the completion of the discharge assessment, the survey team received no further information before the exit conference.
Expired Coconut Milk Not Discarded
Penalty
Summary
The facility staff failed to adhere to professional standards for food service safety by not discarding seven containers of unsweetened coconut milk that had exceeded the best by date of 5/13/24. On 9/04/24, a surveyor, in the presence of the Dietary Manager (DM), observed these expired containers in the dry storage area of the facility kitchen. The DM subsequently removed the containers from storage. The following day, the survey team discussed the issue of the out-of-date coconut milk with the Administrator, Director of Nursing, and the Clinical Services Manager. No additional information regarding this concern was provided to the survey team before the exit conference on 9/05/24.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility staff failed to maintain proper infection prevention and control practices during medication administration on Unit #1. An LPN was observed placing a resident's Breo inhaler in their uniform pocket to transport it into the resident's room for administration. The LPN explained that they had additional items in their hands, including tissues from the medication cart, and did not want to make two trips, leading to the decision to place the inhaler in their pocket. This action was discussed with the facility's Administrator, Director of Nursing, and Clinical Services Manager, but no further information was provided to the survey team before the exit conference.
Failure to Offer Pneumococcal Vaccines to Residents
Penalty
Summary
The facility staff failed to offer pneumococcal vaccines to three residents, leading to a deficiency in immunization practices. Resident #42, who was moderately cognitively impaired and had diagnoses including Type 2 Diabetes Mellitus and Parkinson's Disease, was not offered a pneumococcal conjugate vaccine (PCV15 or PCV20) upon admission. The resident's clinical record lacked documentation of vaccination history or evidence of being offered the vaccine, despite CDC guidelines recommending such vaccinations for adults over a certain age. Similarly, Resident #49, who was cognitively intact and had a history of Type 2 Diabetes Mellitus and Aortic Valve Stenosis, was not offered a PCV20 or PPSV23 vaccine following admission. Although the resident had previously received a PCV13 and PPSV23 before age 65, there was no evidence of being offered the recommended vaccines upon admission to the facility. The facility's policy required documentation of prior vaccinations and timely administration of vaccines, which was not adhered to in this case. Resident #72, who was moderately cognitively impaired with conditions such as Type 2 Diabetes Mellitus and Dementia, was also not offered a PCV15 or PCV20 vaccine upon admission. The resident's clinical record did not contain a vaccination history or evidence of being offered the vaccine, contrary to CDC guidelines. The facility's policy outlined the responsibility of the Infection Preventionist to track and ensure timely vaccination, which was not fulfilled for these residents.
Failure to Offer Updated COVID-19 Vaccine and Obtain Consent
Penalty
Summary
The facility staff failed to offer an updated 2023-2024 COVID-19 vaccine to Resident #49, who was cognitively intact with a BIMS score of 15 out of 15. The resident's clinical record showed their last COVID-19 vaccine was administered on 2/02/23, and there was no evidence of an offer for the updated vaccine. The Infection Preventionist and Administrative Staff Member #4 confirmed the lack of documentation regarding the offer of the updated vaccine. For Resident #42, the facility staff did not provide evidence of education regarding the risks, benefits, and potential side effects of the COVID-19 vaccine, nor did they obtain consent prior to its administration. The resident, who was moderately cognitively impaired with a BIMS score of 8 out of 15, received the vaccine on 6/27/24. The Infection Preventionist and Administrative Staff Member #4 were unable to locate documentation of education or consent. Resident #2, who was severely impaired in cognitive skills and unable to make decisions, received a Moderna Monovalent booster COVID-19 vaccine on 11/16/23. The facility staff failed to provide evidence that the resident's representative received education about the vaccine's risks, benefits, and potential side effects before administration. The Infection Preventionist and Administrative Staff Member #4 confirmed the absence of such documentation.
Failure to Notify Provider of Critical Lab Result
Penalty
Summary
The facility staff failed to notify the provider of a critical lab result for a resident, which was a significant deficiency identified by the surveyors. The resident had a history of cerebral infarction, chronic obstructive pulmonary disease, hypertension, moderate protein calorie malnutrition, depression, and vitamin deficiency. The resident was on medications such as aspirin and Eliquis, which increased the risk of bleeding. A critical lab result indicating a hemoglobin level of 6.1, which is life-threatening, was available on 9/9/23 but was not addressed by a practitioner until the following day. This delay in addressing the critical lab result led to the resident being sent to the emergency room for a blood transfusion due to a gastrointestinal bleed. The Director of Nursing and the Regional Nurse Consultant acknowledged the delay, attributing it to the lab service not notifying them of the critical result. The facility's policy on resident change in condition requires immediate notification of the physician or provider in emergency situations, which was not followed in this case. The survey team discussed this concern with the facility's administration, but no further information was provided before the exit conference.
Failure to Follow Provider Orders for Wound Care and NPO Status
Penalty
Summary
The facility staff failed to follow provider orders for two residents, leading to deficiencies in care. For one resident, the staff did not complete provider-ordered treatments for a surgical wound on multiple occasions across March, April, and May. The resident had a diagnosis of muscle weakness, diabetes, and a chronic ulcer, and was cognitively intact. Despite the comprehensive care plan indicating the need for treatment, the treatment administration records were left blank on several dates, and no evidence was provided to confirm that the treatments were completed. Interviews with staff revealed uncertainty about whether the treatments were done or simply not documented. For another resident, the facility staff did not adhere to a provider's order for the resident to be NPO (nothing by mouth) before a scheduled medical procedure. The resident, who was cognitively intact and had multiple diagnoses including end-stage renal disease and diabetes, was documented to have eaten breakfast on the day of the procedure, contrary to the NPO order. As a result, the resident was unable to receive anesthesia for the procedure. The facility's policy on reviewing physician/provider orders was not followed, and no further information was provided to address this concern before the survey exit conference.
Insulin Administration Error Due to Transcription Mistake
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. The resident, who had a history of type 2 diabetes mellitus with complications and was on long-term insulin use, was admitted to the facility with hospital discharge orders for insulin administration. The orders included a sliding scale for Insulin Lispro Kwikpen, which was incorrectly transcribed by the facility staff, omitting instructions for blood sugar levels between 121 and 150. As a result, the resident did not receive insulin for blood sugar readings of 137 and 143, which should have been treated according to the correct sliding scale. Additionally, the resident's medication administration record (MAR) showed that the Basaglar KwikPen (Insulin Glargine) dose was not administered on one occasion, with no corresponding nurse's note to explain the omission. The staff development coordinator, an LPN, acknowledged the transcription error and its impact on the resident's insulin administration. The issue was discussed with the facility's administration and nursing leadership, but no further information was provided before the exit conference.
Failure to Obtain Ordered Lab Test for Resident
Penalty
Summary
The facility staff failed to obtain a provider-ordered laboratory test for a resident diagnosed with unspecified dementia, bipolar disorder, and depression. The resident's medical records indicated a severe cognitive impairment, with the resident rarely or never understanding others and having severely impaired decision-making abilities. A physician had ordered a Depakote level test to be conducted on a specific date, but the test was not performed as required. The absence of the test results was noted during a review of the resident's medication regimen, and the issue was highlighted in a pharmacist's consultation report. Despite the order being present in the treatment administration record, it was not signed off as completed. When questioned, the facility's staff, including the DON and an LPN, were unable to provide the missing lab results and confirmed that the test was not conducted. The issue was discussed with the facility's administration and regional representatives, but no further information was provided to the survey team before the exit conference.
Incomplete and Inaccurate Clinical Records
Penalty
Summary
The facility staff failed to maintain complete and accurate clinical records for three residents, leading to deficiencies identified during a survey. For one resident, the staff did not document an allergy to Hydrocodone in the clinical record, despite this information being available in the resident's history and physical exam from a transferring hospital and noted in the Nursing Admission Report. This oversight was discussed with the facility's administrative staff, but no further information was provided to the survey team before the exit conference. Another resident's clinical record was incomplete as it lacked advanced directives, despite an order for DNR status being present. The Social Services Annual Evaluation incorrectly stated that the resident had a Living Will, which was not found in the electronic record. Additionally, a third resident's Virginia Department of Health Durable Do Not Resuscitate form was incomplete, with required sections left unchecked. These issues were discussed with the facility's administrative team, but no additional information was provided before the survey's conclusion.
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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 Hampton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marcella Post Acute | 0.9 mi | ★★★★★ | 15 | 0 |
| Langley Post Acute | 1 mi | ★★★★★ | 0 | 0 |
| Atlantic View Post Acute | 2.6 mi | ★★★★★ | 0 | 0 |
| Newport Post Acute | 3.5 mi | ★★★★★ | 0 | 0 |
| The Chesapeake | 3.5 mi | ★★★★★ | 14 | 0 |
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