Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hampshire Center during CMS and state inspections, most recent first.
A resident’s ER medications were crushed despite package directions stating not to crush them. The RN confirmed the facility had always crushed the resident’s tolterodine tartrate ER and potassium chloride ER tablets, even though the blister packs said “Do not chew or crush” and “Do not crush.”
Incomplete and Contradictory Resident Records: A resident’s physician orders, care plan, and Kardex did not match and still contained outdated, conflicting instructions for transfers, eating, and hygiene. The chart showed changing post-op R ankle status, including NWB, CAM boot use, and later WBAT, but the care plan and Kardex were not updated consistently, leaving contradictory transfer guidance such as gait belt use, full lift with sling, and blank transfer documentation.
Residents were exposed to cold shower water and cold shower rooms, with one resident observed shaking after a shower and others reporting repeated cold showers or bed baths because the water heater was not functioning properly. Staff acknowledged the water temperature issue and that showers were being spaced out for recovery time. In addition, an activities area had a visibly dirty floor with food and paper debris, along with multiple garbage bags stacked in the room, despite policy requiring common areas to remain clean and uncluttered.
Food was not stored, prepared, and served in a sanitary manner. Observations found chemicals and cleaning equipment stored in the kitchen area, wet nesting and improperly stored pans, spilled spices, dirty trash can surfaces, and food debris on tables. In the dining room, a cook handled a dinner roll with gloved hands after tray line work without changing gloves or using a utensil. In the nourishment room, no temp logs were present, an outdated peanut butter container was found, food debris and cups were on the floor, and boiled eggs were stored with an open date and no use-by date.
Infection Prevention and Environmental Sanitation Lapses: Surveyors observed soiled lift slings left on lifts and in hallway chairs, an opened package of resident briefs left on a hallway chair, and cleaning wipes left on the floor of a shared bathroom. The dirty laundry room was also warm and humid, and its venting system was not operational, with the MD confirming the vent motor was not working.
Dietary staff records and interview findings showed that 2 of 8 kitchen employees did not have current food handler cards. The Dietary Manager confirmed the cards were not obtained by the expiration dates, and two employees were identified as having worked without up-to-date cards before later obtaining them.
Incorrect menus were displayed and a resident with a consistent carbohydrate diet was given a 3-week menu for a regular diet. Staff confirmed the menu board did not match the meal being served, and the Dietary Account Manager acknowledged the correct menu was not posted. The resident reported meals were often inconsistent, with substitutions, poor temperature, and food texture concerns.
Food was not served in a palatable or attractive condition. A resident reported hard potatoes and mushy vegetables, and a surveyor observed a potato that was firm to touch. A test tray from the kitchen showed bland Salisbury steak, bland scalloped potatoes with firm potatoes, and overcooked-looking California blend vegetables.
Care plan not updated to reflect current continence status. A resident’s care plan and MDS documented the resident as usually continent and using the toilet, but the annual MDS later showed frequent bladder incontinence and always incontinent bowel. During interview, the MDS coordinator verified the care plan should have been updated to reflect the change in bladder continence.
A resident's bed had a 6-inch gap between the footboard and mattress, and the resident was observed in bed with a blanket rolled up on one side of the footboard and feet resting in the gap. The DON verified the gap could cause entrapment, and no further information was provided before the survey ended.
A resident on a consistent carbohydrate diet reported meals were often cold, inconsistent, and frequently substituted. The resident received a 3-week menu labeled for a regular diet instead of the required diet, and the meal ticket showed handwritten changes to items. The Dietary Account Manager confirmed the menu was not the correct diet for the resident.
Failure to administer insulin as ordered: A resident with DM received 54 units of short-acting insulin instead of the prescribed 54 units of long-acting insulin. The clinician was notified, and the physician documented that the error involved accidental administration of the wrong insulin type. The resident stated she was informed of the medication error and complied with the physician's instructions, and the DON confirmed the nurse did not give the medication as prescribed.
A resident experienced significant unintended weight loss due to the facility's failure to document meal intake and provide physician-ordered fortified snacks. The resident lost 11.6% of their weight over 60 days, with 42 out of 174 meals undocumented. Staff interviews revealed communication and system access issues, contributing to the oversight.
A privacy breach occurred when a resident was being undressed by a nurse aide in a shower room without a lock or 'in use' signage. A surveyor entered the room after knocking and receiving no response, finding the resident partially undressed. Staff interviews confirmed the lack of privacy measures, with reliance on knowledge of shower schedules instead of physical indicators.
The facility failed to follow physician's orders for wound care, adaptive equipment, and monitoring. A resident did not receive prescribed wound care treatments, another had a bandage not changed as ordered, and a third did not receive a Kennedy cup during meals. Additionally, 15-minute checks for a resident involved in an altercation were not completed as required. The DON confirmed these deficiencies.
The facility failed to serve meals at safe temperatures, as observed when two residents' breakfast trays were left unattended on a food cart for an extended period. The food items were found to be below the recommended safe serving temperatures, contrary to the facility's policy requiring hot foods to be maintained above 135 degrees Fahrenheit.
The facility failed to maintain accurate medical records for two residents. A resident's acute care transfer form contained an incorrect date, and another resident's meal intake documentation was incomplete, with 42 out of 174 meals undocumented. These issues were acknowledged by the DON and the Nursing Home Administrator, respectively.
The facility failed to thoroughly investigate a resident-to-resident altercation that resulted in a fatal injury. Despite staff witnessing an initial altercation, no interviews were conducted to understand the events leading to the injury. The Director of Nursing acknowledged the lack of witnesses to the fatal fall and the investigation relied on assumptions rather than comprehensive inquiry.
The facility failed to document the repositioning of a resident with a pressure ulcer and did not enforce PPE use for another resident under enhanced precautions. The DON admitted to a lack of documentation and insufficient PPE resources.
A resident with a history of falls due to weakness, osteoarthritis, chronic pain, and hypertension experienced an actual fall on a slippery bathroom floor shared with another resident. The care plan was not updated to reflect this incident, as confirmed by the DON during a survey. The care plan continued to indicate only a risk for falls without acknowledging the actual fall event.
A resident in the facility did not receive timely incontinence care despite activating the call light and expressing the need to be changed. Nurse Aides entered the room but left without addressing the resident's request, turning off the call light. The DON confirmed the resident should have received care, as the care plan indicated extensive assistance was needed due to medical conditions.
A resident with cognitive loss was observed spending extended periods in a common area without engagement or entertainment, despite care plans indicating a need for increased participation in activities. Records inaccurately reflected participation in activities the resident was unable to engage in, and the Activity Director confirmed a decline in participation.
A resident did not receive appropriate treatment to prevent a decrease in range-of-motion due to the facility's failure to apply a prescribed hand splint. Despite a physician's order for a SoftPro resting hand splint to be worn during the day, the resident reported and was observed without the splint. A nurse aide indicated the resident usually does not wear the splint, and the DON confirmed the necessity of the splint.
A resident was found with multiple medications in their room without physician's orders, posing a potential safety hazard. The medications, brought in by the resident's family, were not secured despite the presence of a wandering resident in the facility. The DON did not consider this a safety issue, as the resident was believed to prevent others from taking the medications.
A resident in the facility did not receive physician visits every 30 days for the first 90 days as required. The resident expressed a desire to discuss issues with a physician but was usually seen by a nurse practitioner. A review showed inconsistent physician visits, with a missed visit in April. The DON was unaware of the missed visit and lacked a clear policy on visit frequency, despite state guidelines.
The facility failed to maintain effective infection control practices. A resident's bathroom was found unsanitary, with staff failing to clean adequately. During wound care, an RN breached hand hygiene by opening a door with bare hands. Two NAs entered a resident's room without PPE, despite enhanced barrier precautions being in place. The DON acknowledged these issues.
Crushed Extended-Release Medications
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when it crushed Resident #45’s extended-release medications. Record review showed orders for tolterodine tartrate extended-release 4 mg daily and potassium chloride extended-release 10 mEq and later 20 mEq. The physician order also stated that generic substitution was authorized, the center could participate in therapeutic interchange where permitted by state regulations, and that crushable medications could be crushed. During interview, the RN stated that all of the resident’s medications were crushed. Review of the medication blister packs with the RN showed that tolterodine tartrate extended-release was labeled “Do not chew or crush” and potassium chloride extended-release was labeled “Do not crush.” The RN confirmed the labels and stated, “We have always crushed them [resident’s extended-release medications].” The pharmacist’s recommendations from 10/2025 to present did not identify the crushed medications as an irregularity.
Incomplete and Contradictory Resident Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident #45, whose census was 59, during a complaint survey investigation. Record review showed that the physician orders, care plan, and Kardex did not contain the same information and were not kept aligned as the resident’s status changed. Instead of removing outdated information, the records were updated by adding new information to existing entries, which left conflicting directions in the chart. The inconsistencies involved transfers, eating, and hygiene. The orders reflected changes over time, including non-weight bearing status after a right ankle fall and surgery, later CAM boot use, and then weight bearing as tolerated, with no mention of a sling or total lift/Hoyer use. The care plan contained contradictory entries, including both non-weight bearing and weight bearing as tolerated for the right leg, and different transfer instructions such as CAM boot as needed with gait belt, full lift with purple sling, and call for staff help. The Kardex for the resident’s current status did not mention the CAM boot or weight-bearing status and left the transfer section blank, even though staff used the Kardex to sign off on tasks and review current ADL and transfer needs. The Administrator confirmed that the records should match and not contain information that was no longer relevant.
Cold showers and unclean common area
Penalty
Summary
The facility failed to ensure a safe, comfortable, homelike environment when residents were given showers with cold water and in cold shower rooms. One resident was observed sitting in a wheelchair wrapped in a blanket and visibly shaking after being showered, and stated that the shower was so cold. During observation in the shower room, a nurse aide was seen showering a resident who said the water was cold; the aide asked if the resident wanted to stop, but the resident chose to continue. The maintenance director checked the shower room and water temperatures, which were 69.8 degrees in the room and 94 degrees for the water, and stated that recovery time between showers was usually 20 to 30 minutes because of the water heater issue. The director of nursing stated that residents were offered the chance to check shower temperatures and that showers were spaced out to allow recovery time. Two other residents reported receiving multiple cold showers or bed baths over the prior week or two. One resident stated the water heater had been broken for weeks and that the water was cold even after waiting a long time; another resident stated the water had been cold and that bed baths were difficult. When the maintenance director tested the shower water with the hot side fully open, the highest temperature recorded was 98 degrees Fahrenheit. The maintenance director stated that parts for the water heater were on order and that the facility would cycle through showers to help the water stay hot enough for resident comfort. In a separate observation, the activities area at the end of the 400 hallway had a visibly dirty floor with old food items and paper garbage, and about twenty-two white garbage bags were stacked in the corner and onto a table. The senior administrator stated the bags were Christmas donations and acknowledged awareness of them, while facility policy stated non-resident common areas should be cleaned twice a day and as needed when visibly soiled.
Food Storage and Sanitation Deficiencies in Kitchen and Nourishment Areas
Penalty
Summary
Food was not procured, stored, prepared, distributed, and served in accordance with professional standards based on multiple kitchen and nourishment room observations and staff confirmation. Upon entering the kitchen, a mop bucket and chemicals were observed on the floor next to the bread rack, with mops and brooms leaning near the manager’s office instead of being stored in the janitor closet. Wet nesting was observed on pans on a shelf, two pans were not inverted, spices were spilled on a shelf, the hand sink trash can had brown liquid spilled on top of the lid, and food debris with a sticky substance was noted on the bottom shelves of two of three tables. Staff confirmed each of these conditions. During dining room and nourishment room observations, a cook handled items with gloves during tray line service and then picked up a dinner roll with a gloved hand rather than using a utensil, and did not wash hands or change gloves. In the nourishment room, no temperature logs were present, an outdated peanut butter container dated 12/06/25 was found, and food debris and paper cups were on the floor near the trash can and refrigerator. A refrigerator also contained boiled eggs with an open date of 12/02/25 and no use-by date, and food debris was observed on the wall behind the trash can and on the trash can lid. Staff confirmed these findings and stated the cleaning should have been done earlier.
Infection Prevention and Environmental Sanitation Lapses
Penalty
Summary
The facility failed to maintain and provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. On 12/07/25, surveyors observed four soiled lift slings left out in the 300 and 400 hallways, including one visibly dirty sling hooked to a lift and thrown over the main lifting arm in the 300 hall and another sling draped over a lift in the 400 hall. Additional dirty lift slings were left in chairs at the end of the 400 hallways. The Senior Administrator stated that the slings did not belong on the lifts and should not be left out dirty. Review of the facility policy titled OPS200 safe and homelike environment stated that patient care equipment should be kept clean and properly stored, which was not followed. Also on 12/07/25, surveyors observed one opened package of resident briefs left on a chair in the main hallway of the 100 section, and one container of cleaning wipes on the floor of the shared bathroom for room [ROOM NUMBER]/109. The Senior Administrator stated that cleaning supplies are not supposed to be left in areas where residents and families can access them. In addition, the dirty laundry room was found to be very warm and humid, and its venting system was not operational. The venting system was intended to maintain negative pressure and prevent movement of pathogens into the corridors and clean laundry room. The Laundry Manager notified Maintenance, and the Maintenance Director later confirmed the vent motor was not working and said he was in the process of replacing it, but he was unaware of how long the system had been out of service.
Dietary Staff Lacked Current Food Handler Cards
Penalty
Summary
The facility failed to ensure that all kitchen staff were up to date with their food handler cards. During staff record review and staff interview, surveyors found that 2 of 8 dietary employees did not have current food handler cards. The Dietary Manager confirmed that the cards had not been obtained by the expiration dates. The report identified employee #20, hired on 05/03/2025, who did not obtain a Food Handler Card until 12/01/2025, and employee #71, hired on 08/09/2025, who did not obtain a Food Handler Card until 12/01/2025. The facility census was 61.
Incorrect Menus and Diet Orders
Penalty
Summary
Menus were not properly displayed and did not match the meals being served. During observation, the menu board listed lunch as cheeseburger, cucumber salad, French fries, and peaches, but the lunch actually served was maple sage turkey, stuffing, peas, a dinner roll, and pumpkin pie. Staff confirmed the meal being served was the turkey meal, and the Dietary Account Manager acknowledged that the correct menu was not on display and that evening staff were responsible for hanging the menus before leaving. Resident #49 was also given a three-week menu for a regular diet even though the resident needed a consistent carbohydrate diet. The resident stated that the menu provided was not for the correct diet and reported that meals were often not warm, were inconsistent, and involved many substitutions. The resident also reported vegetables were mushy, potatoes were too hard or not cooked enough, and meat was sometimes tough. Review of the resident’s meal ticket showed a consistent carbohydrate diet with handwritten changes to items, and the Dietary Account Manager confirmed the resident needed a consistent carbohydrate menu.
Food Not Served in Palatable or Attractive Condition
Penalty
Summary
The facility failed to ensure food was prepared and served in a palatable and attractive appearance for residents receiving nutrition from the kitchen. During observation, Resident #49 stated the food was a little warmer that day but reported the potatoes were hard and the vegetables were mush. The resident handed the surveyor a potato that was observed to be firm to touch. A test tray obtained from the kitchen showed Salisbury steak that was bland, scalloped potatoes that were bland with potatoes firm to touch and with bite, and California blend vegetables that appeared mushy and overcooked. The facility policy titled Food Temperatures stated that food and drink are to be served in a palatable, attractive, and safe and appetizing temperature.
Care Plan Not Updated to Reflect Current Continence Status
Penalty
Summary
The facility failed to ensure care plans were updated to reflect current resident needs, affecting 1 of 20 care plans reviewed during the Long Term Care Survey. For Resident #10, the medical record showed a care plan and MDS for bowel and bladder continence that had last been reviewed and updated on 06/06/20, documenting the resident as usually continent of bladder and bowel and using the toilet. However, the resident’s recent annual MDS dated 06/24/24 indicated the resident was frequently incontinent of bladder and always incontinent of bowel. During interview, the MDS coordinator verified that the care plan should have been updated to reflect the change in bladder continence.
Bed Entrapment Hazard
Penalty
Summary
The facility failed to ensure the resident environment under its control was as free from accident hazards as possible. During observation of Resident #7's bed, surveyors found a 6-inch gap between the footboard and the mattress. Resident #7 was observed in bed with a blanket rolled up and placed on one side of the footboard, and the mattress gap was present where the resident's feet rested. During interview, the DON verified that the footboard and mattress gap could cause entrapment. The report states that no further information was provided before the survey ended.
Incorrect Diet Menu Provided
Penalty
Summary
The facility failed to ensure that Resident #49 received the correct diet and menu information for a consistent carbohydrate diet. During interview, the resident stated meals were not usually warm, were cold at times, and were not consistent, and reported that substitutions were frequently made. The resident also stated that the three-week menu provided was for a regular diet rather than the required consistent carbohydrate diet. Observation of the menu confirmed it was labeled for a regular diet with the resident’s name, while the lunch meal ticket for the resident was for a consistent carbohydrate diet and included handwritten changes such as cauliflower in place of broccoli florets and notes indicating no stuffing and mashed items. The resident further reported that vegetables were often mushy, potatoes were too hard and not cooked enough, and meat was sometimes tough. During interview, the Dietary Account Manager confirmed that the resident’s three-week cycle menu was not the correct diet and verified that the resident needed a consistent carbohydrate diet menu.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to follow a physician's order for insulin administration for Resident #3. On 01/20/25 at approximately 8:00 PM, the resident was administered 54 units of short-acting insulin instead of the prescribed 54 units of long-acting insulin. The change-in-condition documentation noted that the clinician was notified at 8:40 PM. Record review showed the resident had orders for NovoLog FlexPen (insulin aspart) to be injected subcutaneously before meals for diabetes mellitus and Basaglar KwikPen (insulin glargine) 54 units subcutaneously two times a day for DM II. A physician note dated 01/20/25 documented that an accidental administration of short-acting insulin instead of long-acting insulin occurred that evening, and that dextrose-containing fluids, high-glucose oral supplements, and close blood glucose monitoring were ordered. During interview, the resident stated she was made aware of the medication error after the facility began implementing interventions and that she complied with the physician's instructions. The DON confirmed that the nurse had not administered the medication as prescribed by the physician.
Failure to Prevent Significant Weight Loss
Penalty
Summary
The facility failed to prevent significant unintended weight loss for a resident, identified as Resident #8, who experienced an 11.6 percent weight loss over 60 days. This deficiency was identified during a survey process, where it was found that the facility did not adequately document meal intake and failed to provide physician-ordered fortified snacks. The resident's weight decreased from 120.4 pounds to 106.6 pounds over the specified period. A Registered Dietician had recommended re-weighing the resident and providing fortified pudding daily, which was ordered by the physician. However, the resident did not receive the fortified pudding on four out of twelve days in August. Further investigation revealed that the resident's meal intake was not properly documented, with 42 out of 174 meals lacking documentation. Interviews with facility staff, including a Registered Nurse and the Certified Dietary Manager, indicated a lack of communication and system access issues that contributed to the oversight. Additionally, the resident's Physician Orders for Scope of Treatment form indicated a provision for feeding through surgically-placed tubes, but the Registered Dietician believed the weight loss was related to TSH levels, which were reportedly under control. The Director of Nursing confirmed the improper documentation of meal intakes.
Privacy Breach During Resident Shower Assistance
Penalty
Summary
The facility failed to provide privacy to residents during shower assistance, as observed during a survey. An incident was noted involving a resident who was being undressed by a nurse aide in a shower room that lacked a lock or 'in use' signage. The surveyor entered the room after knocking and receiving no response, finding the resident partially undressed. Interviews with staff, including a nurse aide and the administrator, confirmed the absence of privacy measures, with staff typically relying on their knowledge of shower schedules rather than physical indicators to ensure privacy.
Failure to Follow Physician's Orders for Multiple Residents
Penalty
Summary
The facility failed to adhere to physician's orders for several residents, leading to deficiencies in care. For Resident #9, multiple physician's orders for wound care treatments, including the application of various creams and gauze, were not followed on several occasions. The Director of Nursing (DON) confirmed that these treatment orders were not executed as required. Similarly, Resident #36 had a bandage on her left shin that was not changed according to the physician's order, which specified daily changes. The DON acknowledged that the bandage had not been changed as ordered. Additionally, Resident #8 did not receive the adaptive equipment specified in her physician's order during a meal observation. The resident was supposed to have a Kennedy cup with all meals, but this was not provided. A nursing assistant confirmed the oversight and attributed it to a lack of familiarity with the dining room procedures. Furthermore, Resident #35 was involved in a possible altercation with another resident, and the prescribed 15-minute checks for 72 hours were not completed, as records for the checks on the third day were missing. The DON confirmed the lapse in completing the checks as ordered.
Failure to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to serve meals at a palatable temperature, as observed during a survey. On the morning of August 13, 2024, breakfast trays for two residents were left on a food cart in hallway 400 for an extended period without being served. The trays were initially brought out at 7:45 AM, but by 8:10 AM, they were still on the cart, and no staff were present to assist the residents. This delay in serving meals resulted in the food cooling to temperatures below the recommended safe serving levels. When the Certified Dietary Manager (CDM) checked the temperature of one resident's breakfast tray at 8:26 AM, the food items were found to be significantly below the required temperature for safe consumption. The puree sausage was at 83.3 degrees Fahrenheit, puree pancakes at 90.5 degrees Fahrenheit, and oatmeal at 94.1 degrees Fahrenheit. According to the facility's policy, hot foods should be maintained at temperatures above 135 degrees Fahrenheit, and any food dropping into the danger zone must be reheated to 165 degrees Fahrenheit for 15 seconds. The failure to adhere to these standards was confirmed by the CDM during an interview.
Deficiencies in Medical Record Accuracy and Meal Intake Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to deficiencies identified during a survey. For Resident #9, the record review revealed an incorrect transfer date on the acute care transfer form, which was noted as 07/08/23 instead of the actual transfer date of 02/22/24. This discrepancy was brought to the attention of the Director of Nursing, who acknowledged the need to investigate further. For Resident #8, a review of meal intake documentation from 06/16/24 to 08/12/24 showed that 42 out of 174 meals were not documented. This lack of documentation was confirmed by the Nursing Home Administrator, indicating a failure to accurately record the resident's meal intake over the specified period.
Failure to Investigate Resident Altercation Leading to Death
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into a possible resident-to-resident altercation that resulted in the death of a resident. The incident involved two residents, one of whom was found on the floor with a head injury and later passed away due to a cerebral hemorrhage. The initial altercation was witnessed by four staff members, where one resident grabbed the sleeve of another, causing a fall. Despite the severity of the incident, the facility did not interview any staff or residents to gather more information about the events leading to the injury and subsequent death. The Director of Nursing stated that there were no witnesses to the fall that resulted in the fatal injury, and the investigation was limited because neither resident could provide an account of what happened. The facility's response was based on assumptions rather than a thorough investigation, as no staff interviews were conducted despite the presence of staff during the initial altercation. The lack of a comprehensive investigation into the incident represents a significant deficiency in the facility's response to alleged violations.
Failure to Implement Care Plan and PPE Protocols
Penalty
Summary
The facility failed to implement a documented intervention for Resident #54, who was receiving wound care for an unstageable pressure ulcer on the left heel. The care plan required the resident to be turned and repositioned every hour and as needed. However, during the survey, the Director of Nursing (DON) admitted that there was no documentation to verify that this intervention was completed, indicating a lapse in following the care plan. Additionally, the facility did not enforce the use of personal protective equipment (PPE) for Resident #50, who was under enhanced barrier precautions due to an indwelling medical device. Nurse Aides #71 and #17 entered the resident's room without wearing the required gown and gloves, despite signage indicating the need for enhanced precautions. The DON acknowledged that there was only one PPE cart per hallway, which contributed to the oversight.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident who experienced an actual fall. The resident, identified as having a risk for falls due to weakness, osteoarthritis, chronic pain, and hypertension, fell on a slippery bathroom floor shared with another resident. The fall occurred because of powder used by the other resident, which made the floor slippery. Despite this incident, the care plan was not revised to reflect the actual fall that took place. The deficiency was identified during a record review and staff interview, where it was noted that the care plan still only indicated a risk for falls without acknowledging the actual fall event. The Director of Nursing confirmed that the care plan had not been updated to include the fall that occurred on the specified date.
Failure to Provide Timely ADL Care to Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to a dependent resident, identified as Resident #50, during the survey process. On the specified date, Resident #50 activated the call light at 5:00 PM, which remained on until 5:10 PM. When Nurse Aide (NA) #71 and NA #17 entered the room at 5:16 PM, Resident #50 expressed a need to be changed due to feeling wet. However, NA #17 responded by saying they would return with a meal tray, and both aides left the room without addressing the resident's immediate need for incontinence care. The call light was turned off without the issue being resolved. The Director of Nursing (DON) later confirmed that Resident #50 should have received incontinence care when requested. A review of Resident #50's care plan revealed that the resident required assistance with ADLs due to a history of cerebrovascular accident (CVA) with monoplegia, weakness, left below-knee amputation (BKA), left knee contracture, and arthritis. The care plan indicated that the resident was independent with eating and locomotion but required extensive assistance with bathing, transfers, and other ADLs, including toileting. The failure to provide timely incontinence care was a deviation from the resident's care plan and needs.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the needs and interests of its residents, specifically Resident #36. Observations over two days revealed that Resident #36 spent extended periods in the common area in front of the nurses' station without any engagement or entertainment, such as television or music. The resident was observed eating meals and sitting for hours without interaction or stimulation, and at one point, was seen crying. The activity care plan for Resident #36 indicated a need for increased participation in activities, yet there was no evidence of efforts to engage the resident in meaningful activities during the observed times. Further record reviews showed discrepancies in the documentation of Resident #36's activity participation. The Minimum Data Set (MDS) indicated that group activities were important to the resident, but the section was not assessed in the most recent update. Additionally, the activity participation records inaccurately reflected active participation in activities that the resident was not physically or cognitively able to engage in, such as exercise and watching TV. The Activity Director acknowledged a decline in the resident's participation and confirmed the resident's prolonged presence in the common area without engagement.
Failure to Apply Prescribed Hand Splint
Penalty
Summary
The facility failed to provide appropriate treatment to prevent further decrease in range-of-motion for a resident identified as Resident #11. During an interview, the resident reported that after a shower, the splint for her right hand was not applied as per the physician's order. A review of the resident's records confirmed a physician's order for a SoftPro resting hand splint to be applied to the right hand in the morning when the resident is in her wheelchair and removed at bedtime, with skin checks to be performed twice daily. An observation later confirmed that the resident was not wearing the splint. A nurse aide stated that the resident usually does not wear the splint, and a registered nurse confirmed the existence of the physician's order. The Director of Nursing was notified and confirmed the necessity of the splint to prevent further decrease in range-of-motion.
Unsecured Medications in Resident's Room Without Physician's Orders
Penalty
Summary
The facility failed to ensure the resident environment was as free from accident hazards as possible, as evidenced by the presence of multiple medications in a resident's room without physician's orders. During an interview with the resident, it was observed that several medications were left on the over-the-bed table and bed. The resident indicated that having these medications in the room was not a concern. When questioned, the RN was unaware of why the medications were present, and the Director of Nursing (DON) mentioned that the resident's family brought them in, and the resident refused a lock box for storage. Further investigation revealed that the medications found in the room included inhalers, nasal sprays, eye drops, muscle rub, and other over-the-counter medications, none of which had corresponding physician's orders. The DON confirmed that the physician would not provide orders for these medications, as the resident already had sufficient as-needed medication. Despite the presence of a wandering resident in the facility, the DON did not perceive the unsecured medications as a safety issue, asserting that the resident would not allow anyone to take them.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were completed every 30 days for the first 90 days for a resident, as required. The resident expressed a desire to discuss certain matters with a physician, but noted that they were usually seen by a nurse practitioner instead. A review of the resident's records revealed that the facility physician's visits were inconsistent, with a notable absence of a visit in April 2023. The Director of Nursing (DON) was unaware of the missed physician visit and was unable to provide a clear policy on the frequency of physician visits, although state guidelines require an initial visit within 72 hours of admission and follow-up visits every 30 days for the first 90 days.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several observations and interviews during the survey process. For Resident #9, the bathroom was found in an unsanitary condition with two bed pans in the bathtub, one containing a brown substance and liquid, and a commode with urine and a black ring. Mixed vegetables were also found on the sink stopper. Resident #9 expressed dissatisfaction with the cleanliness, stating that staff did not adequately clean the area. The Director of Nursing acknowledged the issue upon being informed. For Resident #54, a breach in infection control was observed during wound care performed by RN #41. The nurse repeatedly opened the bathroom door with bare hands to retrieve gloves, compromising hand hygiene. RN #41 admitted to the oversight, acknowledging that gloves should have been prepared in advance. Additionally, for Resident #50, Nurse Aides #71 and #17 entered the room without wearing the required PPE for enhanced barrier precautions, despite signage indicating such precautions were necessary. The aides were unaware of the precautions due to the absence of a cart outside the door, which the Director of Nursing confirmed was a known issue.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 234 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Romney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hampshire Memorial Hospital | 0.1 mi | ★★★★★ | 6 | 1 |
| Complete Care At Dawnview Llc | 13 mi | ★★★★★ | 11 | 0 |
| Keyser Healthcare Center | 17.1 mi | ★★★★★ | 19 | 1 |
| E.a. Hawse Healthcare Center | 18.9 mi | ★★★★★ | 0 | 0 |
| Cumberland Healthcare Center | 21.8 mi | ★★★★★ | 27 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.