Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Willows At Hamburg during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and diagnoses including intracerebral hemorrhage, disorientation, and atrial fibrillation had an unwitnessed fall, but the primary contact/POA was not notified until the next morning. The facility policy required timely notification of the resident representative/provider, yet staff delayed the call after assessing the resident, returning her to bed, and determining she had no apparent injury. Interviews showed staff expectations varied, but leadership stated the notification was not timely and the resident's family should have been contacted sooner.
Failure to complete admission paperwork for a resident admitted for rehab after a stroke. The resident had intracerebral hemorrhage, disorientation, atrial fibrillation, and severe cognitive impairment (BIMS 4/15). Family said only consent to treat and code status forms were signed at admission, while the rest of the packet was delayed, then later emailed for signature. Staff later told the family the resident’s insurance was not covered and there was a $6,000 balance, and the ED said the facility would absorb the cost.
Improper Storage of Personal Food in Nourishment Refrigerator: Staff stored personal food items in a nourishment refrigerator used for resident food. Observation showed an unlabeled pink lunch bag and a salad in a restaurant bag with no name or date. Facility policy required food brought into the facility to be stored separately or be easily distinguishable from facility food, and staff interviews confirmed personal food was supposed to be kept in the break room refrigerator.
Crash cart and oxygen storage access issues were identified in the Legacy Memory Care Unit. Surveyors observed the only crash cart on the unit had an empty O2 tank, while the unit’s oxygen supply room could not be immediately accessed because the keypad lock was faulty and the unit director did not have a key. Facility records showed the crash cart was supposed to be checked and restocked by night shift, but the checklist initials did not match the nurse on duty. One resident in the unit was full code.
A cook in the Memory Care kitchen was observed using a cleaning cloth during food prep without keeping it in the sanitizer bucket. The cloth was left on the counter near food being prepared and continued to be used to wipe the production area, contrary to ServSafe guidance on cleaning and sanitizing food-contact surfaces. The DM, DHS, and ED stated the cloth should have remained in sanitizer water during the food prep session to prevent cross contamination.
Medication storage and labeling were not maintained according to facility procedures and accepted practice for several residents. Surveyors found opened and undated liquid meds on medication carts, medications mixed together instead of separated by route, and expired supplies in the med room; an LPN and the DON stated nurses were responsible for dating opened items, checking expiration dates, and ensuring proper storage and labeling.
A resident with severe cognitive impairment was involved in an incident with a CRMA, where the CRMA allegedly smacked the resident after the resident knocked the CRMA's glasses off. Witnesses reported hearing the resident's head hit the wall, although no visible marks were documented. The facility's investigation found inconsistencies in witness statements, and the CRMA was terminated for not following service standards. The facility's failure to protect the resident from abuse was identified as a deficiency.
A facility failed to implement its abuse policy when a CRMA was physically aggressive with a resident, slapping them and not being immediately removed from the premises. The incident was reported to the DHS 30 minutes later, and the CRMA remained in the facility for about 50 minutes post-incident. The facility's policy lacked guidance on coordinating abuse situations with the QAPI program, leading to a deficiency identified by surveyors.
Delayed Notification After Resident Fall
Penalty
Summary
The facility failed to promptly inform the resident's representative after an unwitnessed fall for one resident, who had diagnoses including intracerebral hemorrhage, disorientation, and atrial fibrillation and was assessed as severely cognitively impaired with a BIMS score of 4 out of 15. The facility policy titled, Notification of Change in Condition, required the resident representative/provider to be notified of a change in condition or diagnostic testing results in a timely manner, and notification attempts were to be recorded in the EHR. The resident's face sheet identified Family 1 as the primary contact and noted she should be contacted at any time and notified of any changes. Progress notes showed the resident fell at approximately 9:18 PM and the representative was not notified until approximately 6:35 AM the following morning. Family 1 stated she was the POA and primary contact, but she did not receive a call, had no missed calls, and had no recent voicemail messages. She reported learning later that the resident had been found on the floor in the room the prior evening, and she stated the nurse apologized for not calling timely. Staff interviews confirmed the fall was unwitnessed, the resident was assessed and returned to bed, and the notification was delayed until later rather than being made promptly after the event. Staff statements varied on what they believed was an acceptable timeframe for notification, with some indicating the family should be notified as soon as possible or within a couple of hours, while others described notifying the following morning after a middle-of-the-night fall. The ADHS and DHS stated that timely notification was expected, and the Executive Director stated eight hours was not timely. The DHS also stated the resident's representative should have been contacted sooner and that the facility did not meet expectations for the resident.
Failure to Complete Admission Paperwork
Penalty
Summary
The facility failed to implement its admissions policy for one resident, who was admitted for rehab after a stroke and had diagnoses including intracerebral hemorrhage, disorientation, and atrial fibrillation. The resident’s admission MDS showed a BIMS score of 4 out of 15, indicating severe cognitive impairment. Review of the resident’s EHR showed admission on 05/21/2026 and discharge on 05/27/2026, but there was no evidence of signed admission paperwork anywhere in the chart. The facility’s admission policy stated it would maintain an admissions policy to ensure fair and impartial admission practices. The resident’s family member stated she was present at admission and signed only a consent to treat form and a code status form, and that she repeatedly asked about the remaining admission paperwork but was told it would be completed later. She stated the paperwork was eventually emailed to her and she was asked to sign and return it, but she wanted time to review it first. At the resident’s first meeting, staff told the family there was a problem with the resident’s insurance and that the stay was not covered, with a balance of $6,000 owed; the Executive Director later stated the facility would cover the cost and the resident was not responsible. Facility staff stated the expectation was that all admission paperwork would be completed and signed within 48 hours of admission, but the Admissions Director said the insurance verification team made a mistake and she was not sure why the paperwork was not presented for signature before discharge.
Improper Storage of Personal Food in Nourishment Refrigerator
Penalty
Summary
The facility failed to store food in a safe manner for 1 of 3 nourishment refrigerators. During observation on 07/10/2026 at 12:00 PM, staff were found storing personal food items in the 200-unit nourishment refrigerator. A later observation of that refrigerator at 12:30 PM showed a large pink lunch bag with no identification and a salad in a restaurant lunch bag with no name or date. The facility policy titled, Food Brought Into Facility, dated 11/27/2017, stated that foods brought in by family and visitors were to be stored so they were separate or easily distinguishable from facility food. During interviews, an LPN stated resident food was labeled with name and date and that staff food was not to be stored in the nourishment refrigerator to prevent possible infection control issues between staff and resident food. An RN stated staff food was in the 200-unit refrigerator and that staff kept their food in the staff lounge refrigerator to prevent potential infection control issues. The DHS and Executive Director both stated staff were to keep their food in the break room refrigerator with their name and date, and that the nourishment refrigerator was for residents only.
Crash Cart and Oxygen Storage Access Issues
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition in the Legacy Memory Care Unit, including the crash cart supplies and access to the oxygen storage closet. Observation on the unit revealed the only crash cart available contained an empty oxygen tank. Review of the facility’s crash cart policy showed the cart should be restocked after use and checked for expired products, a functional suction machine, and a full oxygen tank. Review of the crash cart checklist showed the night shift was expected to document audits and replace supplies as needed, but the initials on the checklist for two dates did not match the night shift nurse on duty and instead matched an LPN who also served as Assistant Director of Health Services. The oxygen supply room on the Legacy Memory Care Unit could not be immediately accessed because the keypad lock was faulty and the unit director did not have a key. The director stated the key was kept by maintenance, and the maintenance director stated he kept the keys for these locks and replaced batteries when notified they were dead. During interviews, the unit director, DHS, and ED all acknowledged that crash carts were expected to be stocked with necessary supplies, including oxygen, and that the empty tank and access issue were identified during the survey observation. Review of code status orders showed one of the 11 residents in the memory care unit was full code.
Improper Use of Cleaning Cloth During Food Preparation
Penalty
Summary
Food was not served and stored in sanitary conditions in the Memory Care kitchen. On 08/06/2025 at 8:55 AM, the cook was observed using a cleaning cloth in the production area without keeping it in the sanitizer bucket during food preparation. The cloth was left lying on the counter surface near the food being prepared, and the cook continued to wipe the production area with the same cloth. The deficiency was identified during review of ServSafe guidance stating that food-contact surfaces must be cleaned and sanitized correctly and that wiping cloths must be stored in a sanitizer solution between uses. In interviews on 08/08/2025, the Dietary Manager, Director of Health Services, and Executive Director each stated that cleaning cloths needed to be kept in the sanitizer bucket during food preparation to prevent cross contamination with food.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store medications according to its document and regulatory guidelines for 3 of 22 sampled residents, including R10, R39, and R61. Review of the facility’s policies showed the medication storage and labeling procedures provided to the SSA surveyor were pharmacy standard operating procedures intended for pharmacy staff, not floor staff. The facility’s Nurse New Hire Checklist dated 02/21/2018 included competency items for signing and dating medications upon opening and arranging the medication cart drawer by route of administration. Observation of the Thoroughbred medication cart revealed R39’s opened and undated bottles of liquid protein and Milk of Magnesia, as well as an opened and undated bottle of Liquid DM cough medication for R10. Medications were not separated by route of administration, with eye, ear, and topical ointments combined and organized by resident name instead of route. Observation of the Thoroughbred medication room revealed multiple expired supplies, including an irrigation tray with piston syringe, FloQ Swab, Accuprism Control Solution, MeSalt Cleansing Dressing, and two opened and undated bottles of plain packing strips. On the Calumet medication cart, a bottle of liquid chest congestion medication for R61 had no opened date, and on the Calumet medication room treatment cart, a half bottle of Dermal Wound Cleanser had no date or resident name. Staff interviews confirmed that nurses were expected to date opened items, check expiration dates, and ensure proper labeling and storage, and the contracted pharmacy account manager stated the pharmacy reviewed carts and medication rooms quarterly but did not manage medical supplies.
Resident Abuse by CRMA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by a Certified Registered Medication Aide (CRMA). The incident involved a resident with severe cognitive impairment, who was admitted with diagnoses including unspecified dementia, pain, and abnormalities in gait and mobility. On the day of the incident, the resident was observed by staff to be agitated and attempting to leave the facility, which led to a confrontation with CRMA7. Witnesses reported that CRMA7 smacked the resident across the face after the resident knocked CRMA7's glasses off, and the sound of the resident's head hitting the wall was heard, although no visible marks were documented. The facility's investigation into the incident revealed inconsistencies in witness statements. Some staff members reported seeing CRMA7 restrain the resident and hearing the resident's head hit the wall, while others were unsure if CRMA7 had hit the resident intentionally. The CRMA involved claimed that any contact with the resident was accidental and occurred while trying to defend herself. Despite the inconclusive findings, CRMA7 was terminated for not adhering to the facility's service standards. The facility's policies on abuse and resident rights were reviewed, highlighting that residents have the right to be free from physical and verbal abuse. The incident was reported to the Office of Inspector General/State Survey Agency on the same day it occurred. The facility's failure to have an effective system to protect residents from abuse was identified as a deficiency, with Immediate Jeopardy and Substandard Quality of Care determined to exist.
Failure to Implement Abuse Policy and Ensure Resident Safety
Penalty
Summary
The facility failed to implement its abuse policy effectively when a resident alleged physical and verbal abuse by a staff member. The incident involved a Certified Resident Medication Aide (CRMA) who became argumentative and physically aggressive with a resident, including slapping the resident's face. The incident was witnessed by two Certified Resident Care Aides (CRCA), who reported the event to the Director of Health Services (DHS) approximately 30 minutes later. However, the CRMA was not immediately removed from the facility and remained on the premises for about 50 minutes after the incident. The facility's policy required immediate action to ensure the safety of residents by suspending the suspected employee pending investigation. However, the policy did not provide guidance on how staff should communicate and coordinate situations of abuse with the Quality Assurance and Performance Improvement (QAPI) program. The policy's inadequacy was highlighted by the fact that the CRMA continued to interact with other staff and residents after the incident, which could have compromised the safety of the resident involved. Interviews with staff revealed that there was a delay in reporting the incident to the DHS, and the CRMA was observed engaging in routine activities after the incident. The facility's initial investigation report did not indicate any immediate physical injury to the resident, although the resident was upset and unable to recall the event. The facility's failure to have an effective system to protect residents from abuse was identified as a deficiency, with Immediate Jeopardy and Substandard Quality of Care being determined by surveyors.
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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 Lexington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lexington Premier Nursing & Rehab | 1.5 mi | ★★★★★ | 0 | 0 |
| Bluegrass Care & Rehabilitation Center | 4 mi | ★★★★★ | 1 | 0 |
| Mayfair Manor | 4.1 mi | ★★★★★ | 7 | 0 |
| The Willows At Citation | 4.7 mi | ★★★★★ | 1 | 0 |
| Hartland Park Health & Rehabilitation | 4.9 mi | ★★★★★ | 13 | 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 October 2026) and official state health department websites.