South Hampton Place staff left the resident unattended in the shower room because the person "preferred to have privacy," according to the Director of Nursing. The practice continued until the resident fell on September 22.
Certified Nurse Aide G told inspectors the resident "refused to allow anyone in the shower with him/her, so staff did not stay in the shower room or monitor the resident while the resident showered." The aide received additional training after the fall to remain in the shower room during bathing.
Registered Nurse D contradicted the privacy explanation. "The resident was not independent with showers and should have been supervised during showers," the nurse said. "He/she did not know staff left the resident unattended during showers."
The administrator defended the practice as following the resident's wishes. "The resident was a private and independent person, so there was not a staff member constantly present in the shower room with him/her," the administrator said. Staff "periodically checked on the resident" and "thought standing outside the door was protective oversight."
That oversight failed when the resident fell.
The Director of Nursing acknowledged the contradiction between safety requirements and the privacy accommodation. "Staff did check on the resident while in the shower room and they stood outside the closed door while he/she showered, so he/she believed staff were providing protective oversight."
Both the administrator and Director of Nursing told inspectors the resident would now be supervised during showers.
Inspectors discovered a second safety violation involving a different resident who required assistance from two staff members for toileting. The resident's care plan mandated two-person transfers but contained no direction for staff to use a gait belt during the transfers.
On September 22 at 11:18 AM, inspectors observed Certified Nurse Aide E and Nurse Aide F helping the resident to the toilet. The resident sat on the toilet without a gait belt around his waist, despite requiring two staff members for the transfer.
CNA E told inspectors the resident "required two staff members to transfer the resident to the toilet" but said "he/she did not use a gait belt when he/she transferred the resident and staff were not required to use a gait belt to transfer him/her."
The aide's understanding contradicted facility policy. The administrator confirmed "the resident required assistance from two staff members during transfers and staff should have used a gait belt." The administrator cited "the potential for injury" as the concern with not using a gait belt and said "he/she did not know the staff did not use a gait belt while transferring the resident."
The Director of Nursing similarly stated that "staff are required to use two members to transfer the resident and to utilize a gait belt during the transfer to prevent potential injury." Like the administrator, the Director of Nursing claimed ignorance: "He/she did not know staff did not use a gait belt when transferring the resident."
The inspection findings revealed a pattern of supervisors unaware of basic safety protocol violations occurring under their oversight. In both cases, management claimed they didn't know staff were ignoring required safety measures.
The shower incident represented a direct contradiction between what nursing staff understood about the resident's capabilities and what actually happened. While one aide said the resident refused supervision, the registered nurse said the resident was not independent and required monitoring.
Federal inspectors classified both violations as causing actual harm to few residents. The shower fall provided clear evidence of harm from inadequate supervision. The transfer violation without a gait belt created documented risk of injury that management acknowledged.
The facility's approach of accommodating resident preferences over safety protocols led directly to the shower room fall. Staff interpreted the resident's desire for privacy as permission to abandon required supervision, despite the person's documented need for assistance.
The resident who fell in the shower told inspectors he couldn't recall whether he cared if staff were present during bathing. This response came after the fall that prompted the safety protocol change.
Both violations occurred in September, suggesting systemic problems with safety oversight at South Hampton Place. Management's repeated claims of ignorance about basic protocol failures indicate inadequate supervision of direct care staff.
The facility now requires shower supervision and proper gait belt use during transfers. These changes came only after inspectors documented the violations and their consequences.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Hampton Place from 2025-11-17 including all violations, facility responses, and corrective action plans.