Below 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 Southampton Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Two residents dependent on assistance with ADLs, medication administration, and in one case dialysis, were discharged from the facility to an unlicensed independent living setting that provided no direct care, despite being repeatedly described by facility staff as a group home. For one resident with multiple chronic conditions, moderately impaired cognition, and a court-appointed guardian, there was no physician-documented basis for discharge, no discharge care plan, no IDT involvement, no documented guardian consent, and key chronic-condition medications and education on Trulicity self-injection were missing from the discharge summary. For the second resident with hemiplegia, ESRD on dialysis, and documented need for nursing home level of care, the record lacked evidence of discharge planning for medication administration, dialysis access management, equipment, or confirmed home health services. In both cases, the SW did not verify the destination’s services or level of care, did not visit the site, and relied on assumptions that it was a staffed group home, while the NP and nursing staff believed 24-hour care and medication administration would be provided, leading surveyors to identify an immediate jeopardy deficiency in discharge planning.
Facility staff discharged a resident with multiple chronic conditions and moderately impaired cognition to a group home without providing written notice to the court-appointed legal guardian, despite a court order granting the guardian authority over all placement decisions. The clinical record lacked a physician-documented rationale for discharge, a documented discharge plan, or evidence of guardian involvement or consent, and only contained social services notes referencing discussions with the resident and the group home. The discharge summary listed the group home address and claimed medication reconciliation was completed, but omitted several medications that a NP had documented should be continued for conditions such as CHF, diabetes, hyperlipidemia, vitamin deficiency, and prior cerebral infarction, and there was no clear evidence that discharge instructions were provided to the resident, representative, or receiving provider.
Facility staff failed to review and revise care plans and to conduct required quarterly interdisciplinary care plan reviews for two residents who were discharged from the facility. One resident with multiple chronic conditions was discharged to a group home, but the care plan continued to state the resident wished to remain LTC and was never updated to include discharge-related problems, goals, or interventions, and no care plan meetings were documented after an earlier date despite subsequent quarterly MDS assessments. Another resident with complex cardiac, neurologic, diabetic, and ESRD conditions had an active care plan focus stating a wish to remain LTC up to discharge, and although the provider documented the resident was stable for discharge to a group home with home health PT/OT, the record lacked evidence that the care plan was revised to include discharge planning, discharge location, or related education and service arrangements.
Facility staff failed to provide adequate medically related social services and discharge planning for two residents with complex medical and cognitive needs who were discharged to independent living settings. One resident, adjudicated incapacitated with a legal guardian and requiring assistance and cueing for ADLs and medication administration, was discharged to an independent apartment setting that provided no direct care, without a documented discharge plan, IDT involvement, or guardian consent, and without verification of services at the destination or education on self‑administration of medications such as Trulicity. Another dialysis-dependent resident with significant comorbidities and a care plan goal to remain LTC was discharged to an independent living facility despite provider documentation referencing a group home with home health PT/OT; the record lacked evidence of discharge planning for medication management, dialysis access care, home health arrangements, or equipment needs beyond a hospital bed, and staff interviews showed they believed the resident was going to a staffed group home rather than independent living.
Facility staff did not attempt or document non-pharmacological pain interventions before administering PRN tramadol to a resident on multiple occasions, despite facility policy and staff expectations that such measures should be tried and recorded prior to giving as-needed pain medication.
Facility staff did not consistently monitor or document blood pressure before administering Midodrine to two residents, despite physician orders and facility policy requiring vital sign checks prior to each dose. This resulted in multiple instances where the medication was given without confirming blood pressure was within prescribed parameters.
Two residents were not treated with dignity when staff prevented one from placing personal items on a window shelf, despite no safety or fire hazard, and delayed meal assistance for another resident who required total help with eating. Both residents were cognitively intact, and staff interviews confirmed the failures to honor their rights to self-determination and timely care.
A resident who was cognitively intact reported concerns about not having enough linens for care. Multiple staff, including CNAs, LPNs, and RNs, confirmed frequent linen shortages, and observation of the linen cart showed insufficient supplies for the number of residents. Staff lacked access to additional linens after the laundry aide's shift, and the facility's policy for maintaining a homelike environment with clean linens was not met.
A resident who was cognitively intact and able to make her own decisions was served grits for breakfast despite a documented dislike for this food. The resident reported frequently receiving food she dislikes, and staff interviews confirmed that food preferences are supposed to be entered into a meal tracker system and followed during meal preparation, but this process was not adhered to in this case.
Unsafe Discharges to Independent Living Without Adequate Planning or Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe, appropriate discharge planning and execution for two residents who were discharged from the facility to independent living settings that did not provide the level of care they required. For the first resident, who had resided in the facility for over three years and had multiple diagnoses including muscle wasting, diabetes, congestive heart failure, atrial fibrillation, cerebral infarction, major depressive disorder, and moderately impaired cognition, the facility discharged the resident to an apartment setting that provided no direct supervision, ADL assistance, or medication administration. The clinical record contained no documented basis from a physician or provider for the discharge, no discharge care plan with goals or identified care needs, and no evidence of interdisciplinary team involvement or care plan review related to discharge. The resident’s MDS indicated the resident did not wish to be asked about returning to the community, and the last comprehensive care plan review months earlier documented no plans to discharge. The first resident had a court-appointed legal guardian authorized to make all decisions, including living arrangements, yet there was no documentation of guardian involvement or consent for the discharge. Facility documents repeatedly referred to the destination as a “group home,” but the location was actually an unlicensed independent living apartment where residents were expected to be independent with all ADLs and where only pill reminders and optional meal preparation were offered. The social worker reported relying on information from the housing owner and did not visit or verify the setting or services, did not document guardian contact, and did not send written notice. The NP and nursing staff believed the resident was going to a licensed group home with a provider and medication administration, and the NP stated the resident required assistance with medications, cueing for hygiene, and could not effectively manage money. The discharge summary omitted several chronic-condition medications previously ordered to continue and contained no documented education on self-administration of Trulicity, despite the resident never having self-administered medications in the facility. The second resident, who had diagnoses including NSTEMI, hemiplegia and hemiparesis after cerebral infarction, type 2 diabetes with proliferative diabetic retinopathy, ESRD requiring dialysis, heart failure, and significant ADL and mobility deficits, was also discharged to the same owner’s independent living setting. The resident’s care plan and MDS documented dependence or need for assistance with toileting, bathing, transfers, mobility, dressing, grooming, and bowel incontinence, and a UAI and Medicaid authorization form indicated a need for nursing home level of care. The care plan also documented the resident’s wish to remain long-term at the facility. The discharge summary from the NP stated the resident was stable for discharge to a group home with home health PT/OT, but the clinical record contained no documented discharge planning addressing medication administration, medication education or training, dialysis access management, medical equipment needs, or confirmation that home health services were arranged. For the second resident, the social worker documented only that the resident was interested in discharging to a group home and had met with the group home representative, with no discharge date initially in place, and later noted the discharge was postponed. The social worker did not verify the level of care or services at the destination, did not visit the site, and acknowledged not knowing what services were provided, having assumed it was a group home. The owner of the receiving setting confirmed it was independent living, not licensed, with no staff providing care or medication administration, only pill reminders and meal preparation if desired. The NP and nursing staff believed the resident was going to a staffed group home with CNAs and nurses providing 24-hour care and medication administration, and the NP stated the resident could not manage medications or dialysis-related needs independently and required 24-hour care. These actions and omissions resulted in residents dependent on assistance with ADLs, medications, and in one case dialysis, being discharged to unsupervised independent living without verified support systems, documented discharge planning, or appropriate involvement of the interdisciplinary team and, for the first resident, without the legal guardian’s knowledge or consent. The surveyors determined that these failures constituted an immediate jeopardy situation related to the facility’s obligation to ensure safe, appropriate discharge planning and execution for residents transferring to lower levels of care.
Removal Plan
- Pause all discharges to a lower level of care pending interdisciplinary team (IDT) review.
- Social Services, Assistant Administrator, and Assistant Director of Nursing completed a retrospective review of all residents discharged to a lower level of care, including verifying that medication administration (including injectables) needs and ADL needs were met; residents identified at risk were contacted, reassessed, and supports/services were arranged or offered as appropriate.
- Implement a Discharge Planning Protocol requiring ongoing IDT collaboration to establish a discharge plan; a physician order aligned with the actual discharge location; resident/representative participation and consent; assessment of functional status and care needs; confirmation of medication access and ability to administer medications; and confirmed follow-up appointments and services.
- Require that residents needing assistance with ADLs, dialysis, medications, or supervision may not discharge to a lower level of care without documented support systems.
- Educate all IDT members (Administrator, Assistant Administrator, DON, ADON, Unit Managers, Business Office, Social Services, Therapy, Licensed Nurses, CNAs, and Providers) on appropriate discharge planning using the Transfer and Discharge Policy and F627 requirements, including IDT collaboration, physician order alignment with actual discharge location, resident/representative participation and consent, functional/care needs assessment, medication access/administration confirmation, and confirmed follow-up appointments/services.
- Ensure any staff not present for immediate education are educated prior to working their next scheduled shift.
- Issue phone contacts and/or letters to all residents discharged to a lower level of care.
- Implement a documented discharge protocol that includes a mandatory checklist of required items to be completed prior to any discharges to a lower level of care.
Failure to Notify Legal Guardian and Incomplete Medication Reconciliation at Discharge
Penalty
Summary
Facility staff failed to provide written notice to a court-appointed legal guardian prior to or at the time of a resident’s discharge to a group home, and failed to accurately complete medication reconciliation on the discharge summary. The resident had multiple significant diagnoses, including muscle wasting/atrophy, diabetes, peripheral vascular disease, congestive heart failure, atrial fibrillation, anemia, major depressive disorder, hypertension, insomnia, affective mood disorder, compulsive sexual behaviors, atherosclerotic heart disease, cerebral infarction, and vitamin and magnesium deficiencies. The MDS documented moderately impaired cognitive skills, need for set-up/touch assistance with ADLs, and occasional incontinence, and Section Q indicated the resident did not want to be asked about returning to the community. The clinical record also contained a court order adjudicating the resident incapacitated and appointing a guardian with authority over all decisions, including living arrangements and placement. The resident’s clinical record documented a discharge to a group home, but there was no documented involvement, consent, or notification of the legal guardian regarding this discharge. There was no documented basis or rationale from a physician or other provider for the discharge to a lower level of care, no documented discharge plan, and no documented request from either the resident or the guardian to leave the facility. Social services notes referenced discussions with the resident and the group home and identified a planned discharge date, later postponed by one day, but did not document any notification to the guardian. The discharge summary listed the group home address and included the guardian’s name and phone number, yet contained no evidence that the guardian was notified or provided written notice of the discharge, including reasons, anticipated date, or destination. The discharge summary stated that pre- and post-discharge medications had been reconciled, but it did not list all medications that were to be continued after discharge. Specifically, aspirin, atorvastatin, ferrous sulfate, spironolactone, and Trulicity were omitted from the discharge medication list, despite a nurse practitioner note indicating these medications were to be continued for treatment of cerebral infarction, hyperlipidemia, vitamin deficiency, congestive heart failure, and diabetes. It was unclear from the record whether the resident, the resident’s representative, or the receiving provider received copies of the discharge instructions. Interviews with the guardian confirmed she was unaware of the discharge until notified by a hospital social worker after the resident was found in the community, and interviews with facility staff confirmed there was no written letter or documented written notice to the guardian, and no documented discharge plan beyond the discharge summary.
Failure to Revise Care Plans and Conduct Quarterly Interdisciplinary Reviews for Discharging Residents
Penalty
Summary
Facility staff failed to review and revise comprehensive care plans and to conduct required interdisciplinary care plan reviews for multiple residents. For one resident with multiple chronic conditions including muscle wasting/atrophy, diabetes, peripheral vascular disease, congestive heart failure, atrial fibrillation, anemia, major depressive disorder, hypertension, and prior cerebral infarction, the care plan last revised in April documented that the resident wished to remain in the facility long term, with goals stating the resident would remain LTC and interventions directing the social worker and care navigation to meet quarterly and as needed regarding the resident’s wishes to remain LTC. The resident was later discharged to a group home, but the care plan was never updated to reflect problems, goals, or interventions related to discharge to the community, despite this change in status. The same resident’s record showed that the last documented interdisciplinary care plan meeting occurred in January, while quarterly MDS assessments were completed in April and July. There was no documentation of care plan review meetings at the time of those quarterly MDS assessments. During interviews, the social worker, who was responsible for updating care plans for discharge status and scheduling care plan meetings, and the assistant administrator confirmed there were no care plan review meetings for this resident after January, and the social worker could not explain why quarterly meetings were not held. The ADON stated that care plan review meetings were supposed to be conducted quarterly around the time of required MDS assessments and that discharge plans were expected to be revised when discharge status changed, but this did not occur for the resident. For a second resident with diagnoses including NSTEMI, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes with proliferative diabetic retinopathy, cerebral infarction, need for assistance with personal care, gait and mobility abnormalities, and hypertensive chronic kidney disease with stage 5 CKD or ESRD, the care plan contained an active focus area stating the resident wished to remain LTC at the facility up to the time of discharge. The discharge summary from the medical provider documented the resident was stable for discharge to a group home with home health PT and OT. However, the clinical record contained no documented evidence that the care plan was reviewed or revised to include discharge planning or the discharge location, and there was no documentation of planning for medication administration or education, dialysis access site management, medical equipment needs, or arrangement of home health services as referenced in the provider documentation. Social work notes only reflected that the resident was interested in discharging to a group home and that the discharge date was postponed, and the unit manager could not recall any care plan meeting to discuss discharge planning for this resident.
Failure to Provide Adequate Social Services and Discharge Planning for Two Residents Discharged to Independent Living
Penalty
Summary
Facility staff failed to provide medically related social services for discharge planning for two residents, resulting in discharges to independent living settings without adequate planning, IDT involvement, or guardian participation. For the first resident, who had multiple complex medical diagnoses including muscle wasting/atrophy, diabetes, CHF, atrial fibrillation, prior cerebral infarction, major depressive disorder, and moderately impaired cognition, the record showed the resident had lived in the facility for over three years and had been adjudicated incapacitated with a court‑appointed guardian authorized to make all decisions, including living arrangements. The MDS documented that the resident did not wish to be asked about returning to the community, and the comprehensive care plan last reviewed eight months before discharge indicated no plans to discharge. Despite this, the resident was discharged to what was documented as a "group home" without a documented discharge plan, without documented rationale for discharge, without a physician/provider order or basis for discharge, and without documented consent or involvement of the legal guardian. Clinical and facility documentation for this resident showed that the psychiatric NP and LCSW noted the resident talking about moving to a group home, but the physician’s recertification shortly before discharge stated the resident was appropriate for nursing home care and required significant help with ADLs, with no mention of community discharge. The social worker documented brief notes indicating discussion of discharge with the resident and the "group home" and set a discharge date, but there was no evidence of IDT care plan review or a written discharge plan identifying post‑discharge care needs, services, or goals. The discharge summary listed a group home address, noted medication reconciliation, and assigned the resident responsibility for scheduling follow‑up with a primary care provider, but left the provider’s contact information incomplete and contained no documentation of education on self‑administration of Trulicity or any other medications, despite the resident not having been assessed or trained to self‑administer injections or other medications in the facility. There was no documentation addressing access to a phone, money management, or specific community supports. Interviews with the guardian, NP, LPN, and social worker revealed that the guardian was not notified or consulted, the NP and nursing staff believed the destination was a licensed group home with medication administration and structured services, and the social worker had not verified the level of care or services at the destination, had not visited the site, and had no written description of services provided. Further investigation with the owner of the discharge destination for the first resident established that the setting was independent living apartments, not a licensed group home, and that residents were required to be independent with all ADLs, with no direct care or medication administration provided, only pill reminders and some meal prep if requested. The NP stated the resident required cueing for hygiene, assistance with medication administration, and could not effectively manage money, and that independent living was not appropriate. The guardian reported learning of the discharge only after being contacted by a hospital social worker when the resident was found on the street with belongings and brought to the ED, and stated she had never been contacted by the facility about the discharge and would have evaluated the location herself if informed. The administrator acknowledged that the guardian should have been involved and that there was no separate documented discharge plan beyond the discharge summary. The facility’s social worker job description, as reviewed by surveyors, required participation in discharge planning, development and implementation of the social care plan, involvement of the resident/family in planning goals, and regular review of discharge plans, which were not reflected in the documentation for this resident. For the second resident, who had resided in the facility for approximately three and a half years, diagnoses included NSTEMI, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes with proliferative diabetic retinopathy, cerebral infarction, need for assistance with personal care, gait and mobility abnormalities, and hypertensive CKD with stage 5 CKD/ESRD requiring dialysis. The care plan contained an active focus area indicating the resident wished to remain long‑term care at the facility. The NP’s discharge summary stated the resident was stable for discharge to a group home with home health PT/OT. However, the clinical record contained no documented discharge planning addressing the resident’s needs prior to discharge, no documentation of arrangements for medication administration post‑discharge, no evidence of medication education or training, and no documented plan for management of the dialysis access site/port. There was no documentation of medical equipment needs beyond later evidence of a hospital bed setup, no evidence that home health services referenced by the provider were actually arranged, and no IDT involvement in discharge planning other than a care plan meeting note on the day of discharge. The only social services documentation for the second resident consisted of two brief notes: one indicating the resident was interested in discharging to a group home after meeting with a group home representative, and another postponing discharge to a later date, with no details on the destination, services, or identified needs. The only document listing the discharge address was an IDT care plan meeting review form on the day of discharge, which also indicated the level of care as long‑term care and showed only nursing and social services present with the resident. The owner of the receiving facility reported that the setting provided apartments and rooms as independent living, with no assistance with daily care, no medication administration, only medication reminders and some meal prep if requested, and that the facility was not licensed as any type of medical facility. Interviews with the social worker, NP, and LPN showed that the social worker stated the resident requested discharge and that she ensured dialysis transport and owner awareness, but could not provide documentation of broader discharge planning; the NP believed the resident was going to a group home described as a small nursing home with CNAs and nurses and stated she was not aware it was independent living and felt the resident needed a group home; and the LPN unit manager believed the resident was discharging to a group home with 24‑hour care. The Director of Social Services confirmed that discharge planning was a social work responsibility and should be documented in the clinical record, which was not evident for this resident.
Failure to Attempt Non-Pharmacological Pain Interventions Before PRN Medication
Penalty
Summary
Facility staff failed to implement a complete pain management program for one resident who required such services. Specifically, the staff did not attempt or document non-pharmacological interventions prior to administering PRN tramadol on multiple occasions in July and August 2024. The resident had a physician's order for tramadol 50mg every six hours as needed for pain, and the medication was administered on several dates without evidence that alternative pain management strategies were tried first. A review of the resident's clinical record, including medication administration records and nurses' notes, did not show that non-pharmacological interventions were offered or attempted before giving the as-needed pain medication. Staff interviews confirmed that such interventions, including touch, relaxation, exercise, or music, should be attempted and documented prior to administering PRN pain medication. The facility's own policy also outlined various non-pharmacological approaches that may be appropriate alone or with medications, but there was no documentation that these were utilized for the resident in question.
Failure to Monitor Blood Pressure Prior to Midodrine Administration
Penalty
Summary
Facility staff failed to monitor and document blood pressure readings prior to administering Midodrine, a medication used to treat low blood pressure, for a resident with a physician's order specifying to hold the medication if systolic blood pressure exceeded 140. The order required blood pressure checks before each dose, but clinical record review showed that on multiple occasions, blood pressure was not obtained prior to administration at scheduled times. This included several missed checks for both morning and afternoon doses across different dates. Staff interviews confirmed that blood pressure should have been checked before each administration to ensure the medication was given within the prescribed parameters. Facility policy also required verification of vital signs prior to medication administration when necessary. Despite these requirements, documentation and monitoring were not consistently performed, resulting in the administration of medication without the necessary assessment.
Failure to Promote Resident Dignity and Timely Care
Penalty
Summary
Facility staff failed to promote the dignity of two residents by not honoring their rights to self-determination and timely care. For one resident with a diagnosis including major depressive disorder and who was cognitively intact, staff instructed her not to place personal items, such as bottles of water and a stuffed animal, on a shelf in front of her room window. The resident reported being told by staff that this was not allowed, citing safety and fire hazard concerns. However, the director of maintenance confirmed that the shelf was attached to the wall and that items would not rest on the air conditioning unit, and the regional director of clinical services stated it was not a fire hazard and that residents were allowed to place items in their windows. For another resident with swallowing difficulties and a history of stroke, who was also cognitively intact and required total assistance with activities of daily living, staff failed to provide a meal in a timely manner. The resident was observed with a lunch tray on the over-bed table, stating he had not eaten and was waiting for assistance. Staff interviews revealed that meal trays for residents needing assistance were left on the cart to stay warm and distributed after other residents were served. The CNA assigned to feed the resident was delayed due to other care tasks and assumed someone else had assisted the resident when the tray was not found on the cart. Both incidents were brought to the attention of facility leadership, including the administrator, director of nursing, assistant administrator, regional director of clinical services, and regional vice president. The facility's policy affirms residents' rights to be treated with respect, kindness, and dignity, which was not upheld in these cases.
Failure to Provide Adequate Linens for Resident Care
Penalty
Summary
Facility staff failed to provide a comfortable and homelike environment for one resident by not ensuring an adequate supply of linens for resident care. The resident, who was cognitively intact and resided on the third floor, expressed concern about the insufficient availability of linens. Multiple staff members, including CNAs, LPNs, and RNs, confirmed that there was often a shortage of linens on the unit, with some stating this occurred daily. Observations of the linen cart revealed that the number of available linens was insufficient for the number of residents on the floor, and staff did not have access to additional linens after the laundry aide left for the day. The linen delivery schedule and actual cart contents showed a discrepancy between what was delivered and what was available for use, with several items in short supply. Staff interviews indicated that only laundry aides and the receptionist had keys to the laundry room, but the receptionist did not actually have access, and the laundry aide locked the room when not present. The facility's policy required clean bed and bath linens in good condition to maintain a homelike environment, but this standard was not met due to the recurring linen shortages.
Failure to Honor Resident Food Preferences
Penalty
Summary
Facility staff failed to honor a resident's documented food dislike, specifically serving grits to a resident who had clearly indicated a dislike for this food item. The resident's annual MDS assessment showed that she was cognitively intact and capable of making her own daily decisions. Despite this, her breakfast tray was observed to contain grits, and her meal ticket also documented her dislike for grits. The resident reported that she receives food she dislikes almost every day. Interviews with dietary staff revealed that resident food dislikes are collected upon admission and entered into a computerized meal tracker system, which is supposed to generate alternative food items on the meal ticket. Staff are expected to follow these meal tickets when preparing trays. However, in this instance, the process was not followed, resulting in the resident receiving a food item she disliked. The facility's policy states that individual food preferences are to be assessed and communicated to the interdisciplinary team, but this was not effectively implemented for this resident.
What surveyors are citing around you — mapped
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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.
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Illustrative
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Nursing homes near Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaufont Health And Rehabilitation Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Forest Hill Health & Rehabilitation | 3 mi | ★★★★★ | 0 | 0 |
| The Virginia Home | 3.2 mi | ★★★★★ | 0 | 0 |
| The Laurels Of Bon Air | 3.3 mi | ★★★★★ | 2 | 0 |
| Glenburnie Rehab & Nursing Center | 3.7 mi | ★★★★★ | 14 | 0 |
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