Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Caleb Hitchcock Health Center during CMS and state inspections, most recent first.
A resident’s care plan failed to address self-injurious finger biting, gnawing, and sucking, and staff documented bloody fingers before the area worsened to infection, gangrene, osteomyelitis, and partial amputation of a finger. Another resident’s care plan did not include seizure history, Keppra use, or recent ulna and facial fractures, despite hospitalizations, tonic-clonic seizures, and an unwitnessed fall with an acute fracture.
Failure to Monitor and Treat Finger Breakdown Led to Infection and Amputation: A resident with cognitive impairment and a history of gnawing and picking at the fingers had bloody breakdown noted on the right hand, but the RN did not document a full assessment or notify the provider, and no ongoing monitoring or treatment was documented. The resident’s finger later became red, swollen, warm, and discolored, and the resident was sent to the ER with gangrene and osteomyelitis, resulting in a partial finger amputation. Staff interviews confirmed the behavior history was not included in the care plan and that the wound should have been assessed and reported when first observed.
A resident with epilepsy and dementia had unwitnessed falls, but the chart did not show all ordered neuro checks and the documented checks lacked the details needed to compare assessments. Another resident had weekly skin assessments completed by an LPN instead of an RN, and when bloody areas were noted on fingers being bitten and sucked, the assessment and follow-up documentation did not describe the wound or ongoing finger monitoring.
Alternating Pressure Mattress Not Set Correctly: A resident with dementia, osteoporosis, and mobility impairment was identified as dependent for ADLs and at risk for skin breakdown. Although an alternating pressure mattress was in use, it was not included in the care plan or orders, and staff observed it set at 240 lbs despite the resident weighing 100 lbs. RN and NA interviews showed the setting was not reflected on the care card and staff were unsure how to obtain the correct information.
Failure to obtain an order, care plan, and staff education for an AFO brace: A resident with gait and mobility issues had a right LE AFO that staff applied daily, but there was no physician order, no clear care plan directions, and no NA education on proper use. The resident said the brace had been prescribed years earlier by a podiatrist and was to be worn each morning and removed at night. RN, OT, PT, and the DNS all acknowledged the missing order and lack of evaluation/documentation.
Unlocked Nursing Supply Closet on Secured Memory Care Unit: A nursing supply closet on the secured Memory Care unit was observed unlocked with multiple supplies inside, including peri wash, mouthwash, creams, razors, wipes, shaving cream, and hand sanitizer. Staff stated the closet was supposed to always be locked and only authorized personnel had access, but it remained unlocked during repeated observations.
A resident with severe cognitive impairment and mobility needs suffered a minimally displaced distal ulnar fracture after a staff member, while providing incontinence care, forcefully pulled the resident by the wrist and shoulder. The staff member was reportedly frustrated and in a hurry, leading to improper handling that caused pain and injury, contrary to the resident's care plan and facility policy.
A resident with severe cognitive impairment sustained a wrist fracture during care when a nurse aide, reportedly frustrated and in a hurry, used excessive force to turn the resident. The incident was witnessed by another aide, who did not immediately report the event to nursing staff as required by facility policy. The delay in reporting the suspected abuse led to a deficiency finding.
Incomplete Care Plans for Self-Injurious Behavior, Seizures, and Fractures
Penalty
Summary
Resident #6 had a deficiency related to an incomplete care plan for self-injurious behaviors. The resident was admitted with diagnoses including UTI, HTN, and COPD, and the admission MDS identified moderate cognitive impairment, dependence for transfers and toileting, and partial to moderate assistance needs for eating, personal hygiene, and showering. The MDS did not identify abnormal behaviors, but the resident’s care plan addressed only being easily agitated and occasionally verbally abusive or aggressive, with interventions such as familiar routines, psych referral as needed, and monitoring mood and behavior changes. The resident’s care plan did not identify the resident’s biting, gnawing, and sucking of the fingers on the right hand, and it did not include interventions to discourage those behaviors or protect the skin from breakdown. Nursing documentation later noted the resident continued to bite and suck on three fingers of the right hand, with the areas described as bloody and without signs or symptoms of infection. A dry protective dressing was applied, but the documentation did not include an assessment or description of the open area or the source of the bleeding. Subsequent nursing notes documented worsening findings to the right middle finger, including redness, swelling, warmth, and discoloration, and the resident was sent to the emergency room for evaluation. The hospital discharge summary identified gangrene, osteomyelitis, and a partial amputation of the right third finger. Interviews with nursing staff and the DNS confirmed the care plan did not include the resident’s gnawing, biting, and sucking behaviors or interventions to address them, and staff stated the behavior had been observed before and during the admission. Resident #1 also had a deficiency related to an incomplete care plan. The resident had diagnoses including epilepsy, a left ulna fracture with routine healing, and fractures of the skull and facial bones. The admission MDS identified severe cognitive impairment, but the care plan addressed only fall risk and ADL assistance, with interventions such as keeping items within reach, using a night light, and toileting assistance every 2 hours. After hospitalization for hypotension and a large blood-filled stool, the resident had two tonic-clonic seizures and was started on Keppra. Later imaging during a hospital workup showed multiple facial fractures and a periorbital hematoma. The resident then sustained an acute distal ulna fracture after an unwitnessed fall, and a later care plan addressed pain related to a left hip fracture with surgical repair, but it did not include the seizure history, antiseizure medication, or the recent ulna and facial fractures. Interview and record review confirmed the care plan did not include these conditions until after surveyor inquiry.
Failure to Monitor and Treat Finger Breakdown Led to Infection and Amputation
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who had a known habit of biting, sucking, and picking at the fingers of the right hand. The resident was admitted with diagnoses including UTI, HTN, and COPD, and the admission record identified moderate cognitive impairment, dependence for transfers and toileting, and no abnormal behaviors. However, a prior physician note obtained later documented a history of critical lower extremity ischemia, toe amputations for gangrene, and revascularization, while the admission physician note did not identify a history of PVD. On 10/18/25, an RN documented that the resident continued to bite or suck on three fingers of the right hand and that the areas were bloody, with no signs or symptoms of infection. The RN placed a dry protective dressing, but did not document an assessment describing the open area or where the blood was coming from, and did not notify the physician. After that note, there was no documented monitoring, physician notification, or assessment of the fingers through 10/25/25, and no treatment order was reflected for the fingers during that period. APRN notes on 10/20/25 and 10/22/25 also failed to document the skin breakdown that had been observed. On 10/26/25, the resident’s right middle finger was found to be red, swollen, warm, dark in color at the top, and with a white patch at the tip. The resident was then sent to the emergency room. A later hospital discharge summary identified gangrene, osteomyelitis, and partial amputation of the right 3rd finger. Interviews with nursing staff and the DON confirmed that the finger breakdown should have been assessed, documented in the wound management section, reported to the provider, and treated when it was first observed, and that the resident had a history of gnawing and picking at the fingers that was not included in the care plan.
Incomplete neuro checks after falls and improper skin assessment documentation
Penalty
Summary
The facility failed to follow professional standards of practice for neurological monitoring after unwitnessed falls for a resident with epilepsy, vascular dementia, and a healing skull and facial fracture. After one unwitnessed fall, the resident was found lying next to a pool of blood and was sent to the hospital; the physician ordered neurological checks and vital signs at specific intervals, but the record did not show the required neuro checks at all ordered times, and the documented checks did not include the information obtained during the assessments. After the resident returned from the hospital, the nursing note documented bruising to both eyes, face, right neck, left knee, and left chest, but did not identify that neuro checks were obtained. After a later unwitnessed fall, the record again showed neuro checks documented as completed and stable, but the documentation did not show what information was obtained during the checks, and one ordered neuro check time was not documented as completed. The facility also failed to follow professional standards of practice related to skin assessment and documentation for another resident with urinary tract infection, hypertension, and COPD who was moderately cognitively impaired and dependent for transfers and toileting. The MAR showed weekly skin assessments were completed by an LPN rather than an RN, and the DNS acknowledged that LPNs cannot complete skin assessments and did not know why the LPN performed them. The resident’s care plan identified risk for skin breakdown and directed weekly systematic skin inspections. In addition, nursing documentation showed the resident was biting, sucking, and picking at three fingers on the right hand, with bloody areas noted and a protective dressing applied, but the assessment did not describe the open area or the source of the blood. Subsequent nursing notes did not identify monitoring or assessments of the right-hand fingers after the bloody areas were observed. The resident later returned from the hospital status post gangrene, osteomyelitis, and partial amputation of the right third finger.
Alternating Pressure Mattress Not Set Correctly
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident who was admitted with dementia, osteoporosis, and mobility impairment. The quarterly MDS identified the resident as severely cognitively impaired, dependent on staff for all ADLs, requiring assistance of 2 with transfers using a mechanical lift, and at risk for pressure ulcers/injuries, although no pressure ulcer was present. The physician’s orders directed Triad paste to the coccyx twice daily, skin prep to both heels twice daily, mechanical lift transfers, and weekly skin checks, but did not include an order for the alternating pressure air mattress that was observed on the resident’s bed. The care plan identified risk for skin breakdown related to incontinence and decreased mobility and included wound-related treatments, transfers, and incontinent care, but did not reflect use of the alternating pressure mattress as a preventive intervention. During observations, the alternating pressure mattress was present on the bed and was set at 240 lbs., while the resident’s documented weight was 100 lbs. The resident was later observed lying in bed with the mattress still set at 240 lbs. RN #1 stated the mattress was being used to prevent skin breakdown, but it was not included in the care plan and there were no settings established for it. RN #1 also stated the NA care card did not reflect that the resident was on an alternating pressure mattress and that the mattress should be set by the resident’s weight. NA #4 stated she was unaware of the mattress setting and did not know where to obtain the information. The facility policy required air mattresses to be ordered based on individualized assessment, provider order, and interdisciplinary review, and to comply with manufacturer recommendations.
Failure to Order, Care Plan, and Educate Staff on AFO Brace
Penalty
Summary
The facility failed to obtain a physician's order, develop a plan of care, and provide staff education for Resident #4's right lower extremity AFO brace. Resident #4 was admitted in January 2024 with diagnoses including difficulty walking, unsteadiness on feet, and abnormalities of gait and mobility. The quarterly MDS identified the resident had no cognitive impairment, was independent with toileting, bed mobility, and transfers, and required partial/moderate assistance with lower body dressing. The resident also had weakness and difficulty walking documented in the assessment. The Resident Care Plan dated 8/27/25 identified that Resident #4 required assistance with ADLs and had an AFO for the right lower extremity, but it did not include directives for application of the brace, goals, or interventions. Observations on 11/18/25, 11/20/25, and 11/21/25 showed the resident wearing shoes on both feet and an AFO brace on the right lower extremity. The brace had metal bars on both sides, a black strap around the ankle/calf area, and extended to the right mid-calf while resting inside a black rubber-soled shoe. Interview and record review showed the NA who applied the brace every morning had not received education or instruction on how to apply it or what it was for, and the NA care card did not identify the brace or when it should be worn and removed. The resident stated the brace had been used for over 30 years, was prescribed by a podiatrist because the arch was starting to collapse, and was to be worn every morning and removed at night. RN, OT, PT, and the DNS all acknowledged there was no physician's order for the brace and no evaluation or staff education had been completed, and the facility policy required a written order, assessment, trained staff, documentation, and regular reassessment.
Unlocked Nursing Supply Closet on Secured Memory Care Unit
Penalty
Summary
The nursing supply closet on the secured Memory Care unit was left unlocked during two observations, even though facility staff stated it was supposed to always remain locked. On 11/18/25 at 10:30 AM, the unlocked closet contained multiple items including peri wash, non-alcohol mouthwash, body cream, barrier cream, body lotion, fingernail clippers, disposable razors, bleach wipes, germicidal wipes, shaving cream, and hand sanitizer. A second observation at 3:00 PM found the closet still unlocked with the same items present. The secured Memory Care unit had 12 residents, and the facility policy for secured storage closets required all storage closets to remain locked when not actively in use and accessible only to authorized personnel. RN #4 stated the closet was supposed to always be locked and that the Nursing Supervisor, Maintenance Director, and Housekeeping Director had keys, while NA #5 stated staff had to ask the nurse to unlock it due to safety concerns. The Facility Operations Manager stated he was informed later that afternoon that the closet door was not locked and was unsure when or how the automatic lock broke.
Failure to Provide Gentle Care During Repositioning Results in Resident Injury
Penalty
Summary
Staff failed to provide gentle care when repositioning a resident with severe cognitive impairment and a history of agitation and aggressive outbursts. The resident, who was dependent on staff for personal hygiene and bed mobility, required two staff members for care and specific interventions to prevent injury and agitation. During incontinence care, one nurse aide grasped the resident's shoulder and wrist and pulled the resident toward herself, despite the resident being slightly resistive and not following commands. The resident was observed to grimace during this interaction, and later assessment revealed swelling and bruising of the left hand, with an x-ray confirming a minimally displaced distal ulnar fracture. Interviews and documentation indicated that the nurse aide involved was in a hurry, became frustrated, and used excessive force while turning the resident. The aide's statements were inconsistent and did not clarify the specifics of the incident. The facility's policy defined abuse as the willful infliction of injury resulting in harm or pain, and the actions taken by the staff during this incident did not align with the required gentle and unhurried approach outlined in the resident's care plan.
Failure to Timely Report Suspected Abuse Following Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to timely report an allegation of abuse involving a resident with severe cognitive impairment and significant care needs. The resident, diagnosed with dementia and dependent on staff for personal hygiene and mobility, was found to have a swollen and bruised left hand during morning care. Subsequent assessment and x-ray revealed a minimally displaced distal ulnar fracture. The incident took place during incontinence care provided by two nurse aides, one of whom was observed to have grabbed the resident's wrist and shoulder and pulled the resident toward her, causing the resident to grimace. Interviews and documentation indicated that one nurse aide was in a hurry and became frustrated during care, using excessive force to turn the resident, who was not following commands and was slightly resistive. The other aide present during the incident acknowledged that care should have been paused and reapproached later, and admitted that the nurse should have been notified immediately when the incident occurred. However, the incident was not reported to nursing staff at the time, resulting in a delay in addressing the potential abuse. Facility policy required immediate reporting of any allegations of abuse, including the willful infliction of injury or pain. Despite this, the staff involved did not follow protocol, and the incident was only investigated after the resident was found with injuries. The failure to promptly report the suspected abuse constituted a violation of the facility's abuse prevention policy.
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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 Bloomfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bloomfield Center For Nursing & Rehabilitation | 2.3 mi | ★★★★★ | 2 | 0 |
| Seabury | 2.5 mi | ★★★★★ | 0 | 0 |
| Touchpoints At Bloomfield | 2.8 mi | ★★★★★ | 19 | 0 |
| Saint Mary Home | 3.5 mi | ★★★★★ | 3 | 0 |
| Hebrew Center For Health And Rehabilitation | 3.7 mi | ★★★★★ | 33 | 0 |
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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.