Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Hemingford Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility’s lobby survey-results binder was not updated with the most recent survey findings or the related plan of correction, containing only older survey results and no complaint citations from the latest cycle. Record review confirmed the absence of the most recent survey, and the administrator acknowledged that the required documents were missing from the survey book.
The facility failed to report an allegation of neglect to the State Agency within the required 2-hour timeframe after a family member alleged that the facility caused a resident’s death through medical neglect. An LPN assessed the resident and found no heartbeat, while the resident’s advance directive and current orders still indicated CPR, and a hospice consult had been ordered but not yet completed. The administrator was informed of the situation, spoke with local law enforcement about the family member’s accusations, but did not notify the State Agency until the following day, which was confirmed by the administrator as not meeting the required reporting timeframe.
A resident with a history of TBI, hemiplegia, and bipolar disorder repeatedly complained that a specific CNA was slow to respond, rude, and problematic during cares. Grievance forms documented that the resident requested the CNA not provide care, agreed to 2-hour rounding in pairs, and that cares in pairs would be implemented for night cares, with the form indicating the care plan was updated. However, review of the Comprehensive Care Plan showed no revisions since the prior year and no interventions reflecting paired staffing or altered care approaches related to these grievances. The ADM acknowledged the CCP was not revised, treated the issue as a personnel matter rather than a care-planning issue, and progress notes contained no documentation of the staffing changes, while the resident reported that the CNA continued to enter the room and that grievances did not result in effective changes.
A resident with significant neurological and musculoskeletal conditions, including hemiplegia, epilepsy, spina bifida occulta, muscle spasms, and contractures, had an order for Percocet 5-325 mg every four hours for pain, with care plan goals to maintain acceptable pain control. Over multiple days, staff documented numerous missed doses on the MAR, frequently using a code indicating "other/see progress notes," while progress notes repeatedly stated that the Percocet was not available, not in stock, or pending pharmacy delivery, and one dose was not given because the resident was sleeping. The resident reported concerns about not receiving pain medication as ordered, particularly at night, and stated that nothing else was done to address their pain, and facility leadership confirmed that the ordered Percocet doses were not administered on the identified occasions.
Nurse aides did not complete the required 12 hours of annual ongoing training. Record review showed 4 of 5 sampled NAs completed only 5.75 to 8.75 hours during their annual training periods, and the DON confirmed the shortfall.
Food preparation failed to follow recipes for beef tips and gravy and peas with pearled onions. A CDM did not reference the recipes, used about 2 lbs of meat instead of 10 lbs, cooked the beef in water without browning or adding onions, and omitted seasonings from the peas. The CDM also began serving trays without taking temps, and food later on the cart was found below hot-holding temp.
Food storage, sanitation, and meal service practices were not followed. The CDM observed expired and undated foods, dirty kitchen and resident refrigerator areas, incomplete temp logs, and an untested dish machine sanitizer. During meal prep and service, the CDM handled ready-to-eat foods with bare hands, skipped HH, used an unclean sink to strain food, did not consistently check food temps, and a room tray was later found below required temp.
Care plans were not kept current for two residents, including one whose code status changed from full code to DNR and another whose PASRR showed SMI but whose MDS and care plan did not reflect it. The facility also could not show that a resident’s representative was able to participate in care plan meetings, and the family reported limited involvement over years of care. The DON, MDS Coordinator, SSD, and ADM all confirmed gaps in documentation and awareness of the missing or inaccurate care plan information.
Dead bugs were observed in numerous light fixtures throughout hallways, common areas, the nurse's station, the entry foyer, the dining room, and the Memory Care Unit, including areas near resident rooms and support spaces. The Housekeeper confirmed the issue and stated housekeeping was not responsible for cleaning the fixtures, while Maintenance said the fixtures were cleaned every 3 months and last cleaned in October.
The facility failed to document a provider clinical rationale and duration for continuing PRN psychotropic medication beyond 14 days for two residents. One resident had PRN lorazepam for anxiety with no end date or documented rationale, and another resident with TBI, anxiety, MDD, and cognitive impairment had PRN lorazepam continued without documentation explaining the extension. The DON could not initially produce the required rationale, and later documentation only noted the medication was for anxiety and to add a stop date in 14 days.
Failure to provide written notice for hospital transfers. A resident was sent to the ER twice and placed on bed hold both times, but the EMR showed no evidence that the resident or representative received written notice explaining the reason for either transfer. The Administrator confirmed the required written notice was not provided.
A resident’s admission MDS was not coded accurately for PASRR status. The resident’s Level II PASRR showed Serious Mental Illness, NF level of care, and unlimited approved days, but the MDS was marked “No” in A1500, which disabled A1510. The MDS Coordinator confirmed the coding error in interview.
Failure to include a resident’s activity preferences in the care plan. Record review showed the resident’s MDS identified important preferences such as being around pets, keeping up with the news, going outside for fresh air, and participating in religious services, but the care plan had no focus area or goals related to those preferences. The DON confirmed the care plan lacked a section for activities preferences and said the MDS Coordinator was responsible for updating it.
A resident with moderate cognitive impairment, CHF, CKD, and diuretic use was not consistently provided adequate fluids despite a care plan and dietary order for 2,062 mL/day and nectar-thick liquids. Staff observations showed the resident repeatedly without fluids in the commons area and dining room, asking for water with dry mouth signs, and eating meals for extended periods without fluids offered; the dietary aide said liquids were passed only if requested and water was kept in room pitchers, while the RD confirmed the expectation was at least two glasses of liquids with meals.
Failure to Ensure Required Physician Face-to-Face Visits: A resident with TBI, psychiatric diagnoses, and moderate cognitive impairment did not have documented PCP face-to-face visits at the required intervals. The record showed only two MD visits, while the remaining provider encounters were with APRNs, a DPM, a PA-C, Hospice RN staff, or unidentified signatures. The ADM confirmed the facility could not provide physician notes for the reviewed dates and acknowledged it had been separating provider visits by payer source.
The facility failed to document provider review and response to pharmacist recommendations from the monthly drug regimen review for two residents. One resident had repeated pharmacist suggestions to discontinue unused PRN medications, and the chart showed no provider documentation of review or action. Another resident with TBI, anxiety, MDD, dissociative disorders, and moderate cognitive impairment also had no physician note addressing pharmacy medication-change recommendations.
Failure to submit timely investigation report for suspected neglect. A resident with pancreatic cancer, rhabdomyolysis, DM2, and a TBI was found wearing an overly wet and soiled brief, and an NA from the prior shift was suspected of leaving the resident in the brief for an extended period. The incident was reported to the state agency, but the facility did not submit the final investigative report within the required 5 business days, as confirmed by the ADM.
A resident with multiple chronic conditions and dependence on staff for mechanical lift transfers was left waiting for incontinence care after requesting help, despite repeated attempts to get assistance from nursing staff. The resident reported prior delays of 30 minutes to 2 hours, and observation showed the resident waiting in the room and later in the hallway before care was finally provided. The facility also failed to obtain ordered BMP and Hgb A1c labs for another resident with CKD, anemia, dementia, CHF, and hypokalemia, and there was no note showing the MD was notified that the labs were not completed.
Failure to prevent worsening pressure injury care occurred for a resident with TBI, dementia, COPD, and CHF. A coccyx skin breakdown progressed from a small open area to a heavily draining, foul-smelling sacral wound with eschar, undermining, and infection, later described by the wound clinic NP as effectively a Stage 4 pressure injury. The record showed limited interventions beyond barrier cream, dressing changes, and repositioning, and the DON stated there were no additional interventions besides repositioning and wound care.
The facility did not employ a full-time Registered Dietitian or a certified Food Service Director, affecting 27 residents. The facility's assessment highlighted the need for a qualified nutrition professional. The Kitchen Supervisor lacked necessary certifications, and the dietitian had resigned.
The facility failed to store, label, and manage food items properly, risking foodborne illness for all residents. Observations included inadequately labeled garlic, unlabeled ground meat, improperly stored diced meat, outdated cooking wine, uncovered coffee carafes near a sink, and outdated sandwiches. The Kitchen Supervisor was unaware of these requirements.
The facility failed to prevent potential cross-contamination by not ensuring hand hygiene during laundry distribution and not using gowns as required by policy when sorting soiled linens. A staff member distributed laundry to residents without performing hand hygiene, and only gloves were used during sorting, contrary to the policy that required gowns.
The facility did not ensure a nurse aide completed initial orientation with abuse training, potentially affecting all 27 residents. The aide, employed since October, could not identify types of abuse or reporting procedures. The Administrator confirmed no evidence of completed training.
The facility did not develop and implement baseline care plans within 48 hours of admission for five residents, as required by policy. The DON confirmed the oversight, stating that the facility had never provided copies of the care plans to residents or their representatives. The residents had various medical conditions, including dementia and chronic pain, requiring timely care planning.
A resident with severe cognitive impairment and aggressive behaviors was involved in multiple altercations with other residents, resulting in injuries. The facility's interventions were inadequate and often duplicated, failing to prevent further incidents, as confirmed by the DON.
A resident alleged a theft of 4 million dollars, but the facility failed to report the incident to the state agency within the required 24 hours and did not submit an investigation report within 5 working days. The delay was confirmed through interviews with the DON and NHA, highlighting non-compliance with the facility's policy and state law.
The facility inaccurately coded the MDS for two residents, leading to errors in documenting active diagnoses and medication use. One resident was incorrectly noted as taking an anticoagulant instead of an antiplatelet, and a contraindicated GDR was not documented. Another resident was wrongly listed as having septicemia, despite no ongoing condition. An MDS-RN confirmed these discrepancies.
A facility failed to provide a complete discharge summary for a resident, omitting the recapitulation of stay. The facility's policy requires this summary to include a recap of the resident's stay and a final status summary at discharge. However, the discharge planning document was incomplete, as confirmed by the DON.
A facility failed to ensure a resident's drug regimen was free from unnecessary drugs, as two prophylactic antibiotics lacked stop dates and valid indications for use. The facility's policy required complete antibiotic orders, but a review revealed deficiencies in the orders for Macrobid and bacitracin-polymyxin ophthalmic ointment. The DON confirmed these issues.
The facility failed to maintain the nutritive value of pureed food for two residents. Cook-A prepared meals by blending chicken and dumplings, peas, and cornbread with unmeasured hot water, affecting the food's nutritive value. The facility lacked recipes for diet modifications and a policy for preparing mechanically altered foods. The Kitchen Supervisor was unaware of the impact of adding water, and the Administrator confirmed the absence of relevant policies.
The facility failed to serve food in the texture ordered by medical providers for two residents. Despite orders for mechanical soft diets, the cook prepared and served pureed food. The facility lacked a policy for preparing modified texture foods, and the administrator was unaware of the inconsistency.
The facility did not perform required nurse aide registry checks for adverse findings on four employees, including a cook, an LPN, and two nurse aides, hired between August and October 2024. This oversight was confirmed by the Administrator and could potentially affect all 27 residents.
A resident's elopement was inaccurately reported by the DON, with inconsistencies in the dates and times of the incident and notifications to APS and the facility administrator. The report misstated the elopement date, notification times, and the resident's return time, as confirmed by the DON.
A resident with severe cognitive impairment and a history of wandering was moved from a locked Memory Care Unit to a non-locked unit, despite ongoing risk behaviors. The facility's interventions, including exit alarms and behavior logs, were insufficient, leading to the resident eloping and being found outside the facility. Safety checks were implemented post-incident but were later discontinued, highlighting inadequate supervision and intervention planning.
A resident experienced a 7.4% weight loss over one month, but the facility failed to notify the resident's POA or PCP as required by policy. The weight changes were documented, but staff did not report the significant change, leading to a deficiency in regulatory compliance.
The facility failed to assist a dependent resident with toileting, as evidenced by multiple observations and interviews. Despite the resident's need for total assistance and the facility's policy requiring timely response to call lights, staff did not provide the necessary help, leaving the resident without assistance for an extended period.
A resident experienced a 7.4% weight loss over one month, which was not properly documented or addressed by the facility staff. The facility failed to follow its policy for significant weight changes, leading to a deficiency in providing adequate food and fluids to maintain the resident's health. The resident frequently refused meals, and there was no consistent documentation of their nutritional intake or the provision of high-calorie supplements.
The facility failed to prepare and administer the correct dosage of medication for two residents, resulting in a medication error rate of 7.69%. An LPN did not measure Diclofenac Gel 1% correctly for one resident and administered an incorrect amount of Miralax to another. The facility's policy on verifying medication details was not followed.
Failure to Provide Access to Most Recent Survey Results and Plan of Correction
Penalty
Summary
The facility failed to provide residents, family members, legal representatives, visitors, and the public with access to the most recent survey results and plan of correction as required. During an observation in the lobby, surveyors noted a 3-ring binder labeled “Hemingford Care Center Survey Results,” which, upon review, contained survey results only up to a survey ending in December 2024. The binder did not include the results of the most recent survey that ended on 2/2/26, nor did it contain the corresponding plan of correction for that survey. Record review further showed that there were no citations related to complaints following the previous survey included in the book. In an interview, the administrator confirmed that the required documents were not included in the survey results book. No specific residents or their medical conditions were mentioned in relation to this deficiency, and the issue centered on the facility’s failure to maintain and make available up-to-date survey documentation for review by stakeholders.
Failure to Timely Report Allegation of Neglect Related to Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect to the State Agency within the required 2-hour timeframe. A family member of Resident 7 alleged that the facility caused the resident’s death through medical neglect. Nursing notes document that the resident died in the facility, with an LPN-C assessing the resident and finding no heartbeat at 2:39 PM. At the time of death, the resident had an advance directive indicating a desire for CPR if the heart stopped, and the physician orders and care plan in Point Click Care still indicated CPR. A hospice consult had been ordered but had not yet occurred. The administrator was updated about the situation at 3:03 PM, and the family member, while in the facility, loudly accused the facility of having murdered the resident, causing distress to other residents. Subsequently, the administrator spoke with local law enforcement and provided the sheriff with requested information regarding the family member’s allegations. Despite receiving the allegation of neglect from the family member on the date of the resident’s death, the facility did not notify the State Agency of the allegation until 1:51 PM the following day. In an interview, the administrator confirmed that the State Agency was not notified within the required 2-hour timeframe. This delay in reporting the allegation of neglect to the State Agency constitutes the cited deficiency.
Failure to Update Care Plan After Resident Grievances About CNA Care
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s Comprehensive Care Plan (CCP) to reflect care changes made in response to the resident’s grievances. The resident, admitted in 2023, had multiple significant diagnoses including sequela of unspecified intracranial injury, personal history of traumatic brain injury, hemiplegia of the left nondominant side, and bipolar disorder. On one grievance dated late March 2026, the resident reported that a specific nursing assistant (NA-A) did not respond when called and was rude and slow to help; the grievance documentation showed the resident requested that NA-A no longer provide care and agreed to 2-hour rounding in pairs, but the form indicated the plan of care was not updated. A second grievance in early April 2026 documented the resident’s concern that CNAs were waking the resident at night, taking too long for cleanup, and being rude or dismissive. The facility’s follow-up section for this second grievance stated that the care plan was updated, that NA-A was educated on tone and approach, and that cares in pairs were implemented for all night cares, with the form marked that the plan of care was updated. Despite these documented changes, record review on April 21, 2026 showed that the behavior section of the resident’s CCP had not been revised since October 2025 and still only described a pattern of accusatory statements and unrealistic demands, with no interventions reflecting paired staffing or altered care approaches related to the grievances. The Administrator confirmed that the CCP interventions for this resident had not been revised since 2025, acknowledged that instead of updating the care plan they wrote progress notes, and further confirmed that the notes from early April 2026 did not address the staffing changes during cares. The Administrator stated they viewed the issue as a personnel matter affecting staff rather than the resident’s plan of care and therefore did not document changes in the CCP, and also confirmed that the care concern from the April grievance was not documented as indicated on the grievance report. The Regional Nurse Consultant confirmed the CCP should have been updated for staffing during cares. The resident reported filing several grievances against NA-A, stated that none of them worked, and that NA-A still entered the room. The DON confirmed that only NA-A and young female staff were required to enter the resident’s room in pairs, and the resident later confirmed that NA-A continued to go into the room, indicating that the documented care changes were not reflected in the CCP.
Failure to Provide Ordered Narcotic Pain Medication Due to Lack of Availability
Penalty
Summary
Surveyors identified a deficiency in medication administration when a narcotic pain medication (Percocet 5-325 mg) was not provided as ordered to one resident with significant neurological and musculoskeletal conditions. The facility’s medication policy required medications to be administered according to prescriber orders and time frames, and the resident’s care plan included goals to be free from pain or at an acceptable level of discomfort, with an intervention to administer Percocet as ordered for pain and muscle spasms. The resident, who had a history of intracranial injury with loss of consciousness, hemiplegia, epilepsy, spina bifida occulta, muscle spasms, restless leg syndrome, traumatic brain injury, and contractures of both ankles, right toes, and both hands, had a standing order for Percocet 5-325 mg, one tablet every four hours for pain starting in August 2025. Record review showed multiple missed doses documented on the March and April 2026 MARs, with chart code "9" (other/see progress notes) used repeatedly instead of administering the medication. Progress notes on several dates documented that Percocet was not available, not in stock, or that staff were awaiting pharmacy delivery, including 10 consecutive missed administration times over two days and additional missed doses on later dates. On one occasion, a dose was marked as not given because the resident was sleeping. Interviews with the resident confirmed concerns about not receiving pain medication as ordered, especially at night, and the resident reported that the facility had not done anything else to help with their pain. The DON, interim DON, and Administrator each confirmed that the resident did not receive Percocet as ordered on the identified dates and times.
Nurse Aides Did Not Complete Required Annual Training Hours
Penalty
Summary
The facility failed to ensure 4 of 5 sampled nurse aides completed the required 12 hours of ongoing annual training based on their dates of hire. Record review showed the facility assessment required in-service training for nurse aides to be sufficient to ensure continuing competence and to provide no less than 12 hours per year. Review of the employee contact list identified NA-I, NA-J, NA-A, and NA-L, and review of each aide’s ongoing training records showed they completed 8.25 hours, 5.75 hours, 8.75 hours, and 8.75 hours respectively during their annual training periods. During interview, the DON confirmed that NA-I, NA-J, NA-A, and NA-L had not completed the required 12 hours of annual ongoing training.
Food Preparation and Holding Temperatures Not Followed
Penalty
Summary
The facility failed to follow recipes to conserve nutritive value, palatability, and proper temperatures of foods served to residents. During observation of food preparation, the Certified Dietary Manager (CDM) prepared beef tips and gravy and peas with pearled onions but did not reference the recipes while cooking. The CDM opened two 2.5-pound bags of peas that contained no pearled onions, cut open an unknown-size bag of beef tips with scissors, and used bare hands to pry open and pour the meat into a pan of water. The CDM also did not brown the beef or add onions as directed by the recipe, and instead cooked the meat in water. The CDM stated the meal was being prepared for all 33 residents and that extra servings were usually made. Record review showed the beef tips and gravy recipe required 10 pounds of meat for 40 portions and directed that the meat be browned in a skillet with shortening until it reached 165 degrees Fahrenheit for 15 seconds, then simmered with chopped onions for 30 minutes. The peas and pearled onions recipe required 10 pounds of peas and pearled onions for 50 portions and directed that black pepper, salt, basil leaves, and margarine be mixed in, but none of those items were added. The CDM confirmed that only about 2 pounds of meat were used, that none of the seasonings were added, and that the peas and pearled onions had not come in, so onion powder would be used for flavor. Later, the CDM began serving the memory unit without taking temperatures until cued, and the food on the room tray cart was later observed at 119 degrees Fahrenheit for the beef tips and gravy and 117 degrees Fahrenheit for the peas. The CDM also confirmed the food was not hot and would have had better flavor if the recipe had been followed.
Food Storage, Hand Hygiene, and Temperature Monitoring Failures
Penalty
Summary
The facility failed to use or dispose of expired and improperly stored foods, failed to maintain kitchen and resident food storage areas in a clean condition, and failed to document required refrigerator, freezer, and dish machine sanitizing checks. During the initial kitchen tour, the dish room, stove, stove hood, prep counters, dry storage room, and resident dining room refrigerators were observed with food splatter, dried residue, dust, and other buildup. Multiple food items were found without dates or with expired dates, including grape jelly, cheese slices, cooked ham, biscuits, baking powder, and items in the resident refrigerators. The kitchen and dining room temperature logs also contained numerous blank entries, and the CDM confirmed the cleaning schedule was not being followed and that the dish machine sanitizer had not been tested as required. During meal preparation and service, the CDM handled food with bare hands and without hand hygiene, including opening packages and touching ready-to-eat foods while plating sandwiches and room trays. The CDM placed beef tips, peas, and noodles into steam table pans, did not initially verify the beef tips temperature before draining, and used the middle compartment of the 3-compartment sink to strain food even though it had not been cleaned and contained hardwater stains and unknown particles. The CDM also confirmed the recipe was not followed because the correct amount of meat and seasonings were not used for the meal. During meal service, temperatures were not consistently checked until prompted, and the CDM later confirmed that food temperatures were not being monitored consistently after meal service. The beef tips and gravy, noodles, peas, and soup were observed at various temperatures during service, and a room tray delivered to the conference room was later found to have beef tips and gravy with noodles at 119 F and peas at 117 F. The CDM also confirmed that the room tray did not hold the required temperature and that the food tasted cold and bland in flavor. Facility records showed only partial documentation of food temperatures after meals, with only one or two items often being recorded.
Care plans not updated for changed resident conditions and family participation not documented
Penalty
Summary
The facility failed to review and revise care plans when resident conditions changed for two residents. One resident’s care plan listed the resident as full code and directed staff to perform CPR, but the resident’s advance directive stated the resident did not want CPR, blood transfusions, tube feedings, or transfer to an acute care hospital. The DON confirmed the care plan information was not accurate, and the MDS Coordinator stated they were not aware the resident’s code status had changed from CPR to DNR. The facility also failed to accurately reflect a resident’s PASRR status in the care plan. The resident’s Level II PASRR showed the resident met the federal definition of Serious Mental Illness and was approved for nursing facility level of care, but the admission MDS indicated the resident was not currently considered to have serious mental illness or intellectual disability. The care plan contained no evidence of the Level II PASRR finding or related goals and interventions. The MDS Coordinator confirmed the MDS was not coded accurately and stated the information was not on the care plan because they were not aware of the PASRR result when the MDS was completed. The facility further failed to ensure a resident representative was able to participate in care plan development. The resident had diagnoses including chronic heart failure, chronic pain, and displacement of an esophageal anti-reflux device, and the MDS showed moderate cognitive impairment, dependence for most ADLs, nectar-thick liquids, and diuretic use. The family member stated they had only attended three care plan meetings since admission seven years earlier and felt they were not being included in decisions about care, medications, and therapies. The facility could provide only one care conference summary showing the family was invited but did not attend, and staff could not produce documentation of other care conferences or confirm when the last meeting occurred.
Dead Bugs Found in Multiple Light Fixtures Throughout Facility
Penalty
Summary
The facility failed to ensure that light fixtures throughout the halls and common areas were free of deceased bugs, affecting the resident environment. Based on observation, numerous dead bugs were seen in light fixtures outside the administrator's office, outside the main dining room, in the hallway outside multiple resident rooms, outside the beauty salon, in the nurse's station, in the entry foyer, outside the laundry room doors, outside the employee lounge, outside the Physical Therapy room, and in the Memory Care Unit dining room and hallway areas. The facility census was 33 residents. The facility policy dated [DATE] stated that resident care areas, common areas, and support spaces would be maintained in a clean, orderly, and sanitary condition at all times. During interview, the Housekeeper confirmed the light fixtures had bugs in them and stated housekeeping was not responsible for cleaning them. Maintenance stated the light fixtures were cleaned every three months and that the last cleaning occurred in October, and Maintenance confirmed the light fixtures needed to be cleaned.
Failure to Document Rationale for Extended PRN Psychotropic Use
Penalty
Summary
The facility failed to obtain a clinical rationale from the provider to continue PRN psychotropic medications beyond 14 days for 2 sampled residents. The facility’s psychotropic medication use policy stated that if a prescriber believes it is appropriate to extend a PRN order beyond 14 days, the rationale and duration must be documented. For Resident 13, who was admitted with anxiety and had a PRN lorazepam order for 0.5 mg every 8 hours as needed, the January 2026 MAR and progress notes showed the order had no end date or duration, and a review 22 days after the refill order found no documentation of a clinical rationale for continuing the medication. A script later written by the provider stated to continue the current PRN Ativan order and re-evaluate when the provider saw the resident, but no rationale or duration had been documented at the time of review. For Resident 6, who had diagnoses including traumatic brain injury, anxiety disorder, major depressive disorder, obsessive-compulsive personality disorder, and dissociative identity disorder, the record showed a PRN lorazepam order for anxiety dated 9/29/2025. The resident’s MDS showed moderate cognitive impairment, substantial assistance needed for bathing, transfers, and bed mobility, and no behaviors documented in Sections D and E. Review of progress notes and physician orders from 9/30/2025 through 1/28/2026 found no documentation explaining why the PRN lorazepam was continued beyond 14 days. During interview, the DON initially provided only an informed consent form, and later a telephone order was produced stating lorazepam was for anxiety and to add a stop date in 14 days.
Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to a resident and the resident’s representative regarding the reason for the resident’s transfers to the hospital. Record review showed the resident was transported to the emergency room on 1/2/2026 at 3:11 PM and was confirmed admitted to the hospital at 5:14 PM that day, and was again sent to the emergency room on 1/19/2026 at 7:10 PM with hospital admission confirmed on 1/20/2026. Bed hold agreements were completed for both hospitalizations, but the resident’s electronic medical record contained no evidence that written notice of the reason for transfer was provided to the resident or representative for either hospital admission. During interview, the Administrator confirmed that the required written reason for the transfers was not provided.
Admission MDS Incorrectly Coded for PASRR Status
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to accurately code the admission MDS for Resident 20 in relation to the Level II PASRR. Resident 20’s Level II PASRR dated 10/28/25 documented that the resident met the federal definition of Serious Mental Illness, met Nursing Facility Level of Care, and had unlimited approved days. However, the admission MDS dated [DATE] was coded “No” in Section A1500 for whether the resident was currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, which disabled Section A1510. The MDS Coordinator signed the assessment on 11/9/2026, and later confirmed in interview on 1/29/26 at 9:10 AM that the PASRR indicated Serious Mental Illness and that the admission MDS was not coded accurately.
Failure to Include Resident Activity Preferences in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 11, based on record review and interview. The resident’s admission MDS dated 9/29/2025 identified activities that were very important to the resident, including being around animals such as pets, keeping up with the news, going outside for fresh air when the weather is good, and participating in religious services or practices; the resident also identified doing things with groups of people and doing favorite activities as somewhat important. However, a record review on 1/27/2026 of the resident’s undated care plan showed no evidence of a focus area or goals related to these activity preferences. During an interview on 1/28/26 at 2:47 PM, the DON confirmed the care plan did not contain a section related to the resident’s activities preferences and stated the MDS Coordinator would be responsible for updating this in the care plan.
Inadequate Fluid Provision for Resident on Diuretics and Nectar-Thick Liquids
Penalty
Summary
The facility failed to ensure adequate fluids were provided to a resident who had a history of essential hypertension, chronic kidney disease stage 3, urinary incontinence, urinary tract infections, Influenza A with hypoxia, and a diagnosis of congestive heart failure noted by the RD. The resident’s MDS showed moderate cognitive impairment, dependence on staff for all ADLs except eating and drinking with set up and supervision, nectar thickened liquids, and diuretic use. The care plan identified a fluid balance problem related to diuretic use, decreased thirst mechanism, and thickened fluid order, with interventions to keep the resident free of dehydration symptoms and to provide access to nectar thick liquids of choice whenever possible. The dietary assessment stated the resident was on two diuretics, nectar thickened liquids, and required 2,062 mL daily, with encouragement of intake in the dining room and promotion of fluid intake. Fluid intake records showed multiple days of intake below the daily requirement, including 240 mL, 780 mL, 0 mL, 720 mL, 30 mL, 780 mL, 550 mL, 810 mL, 1,060 mL, 960 mL, 1,600 mL, and 720 mL. Observations showed the resident sitting in the commons area and dining room without fluids available on multiple occasions, including while sleeping in a wheelchair, asking repeatedly for water and licking lips, and having meals in front of them for extended periods with no fluids offered. Staff were observed obtaining water only after several minutes when the resident requested it, and a dietary aide confirmed liquids were passed at meals per resident request and that no water was passed because residents get it in pitchers in their rooms. The RD confirmed the expectation was that residents would have at least two glasses of liquids with meals and stated the resident’s fluid intake was very important because of CHF and diuretic use.
Failure to Ensure Required Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure that one resident was seen face-to-face by a primary care physician at the required intervals when alternating visits with a non-physician practitioner. Resident 6 was admitted with diagnoses including unspecified head injury, diffuse traumatic brain injury with loss of consciousness of 30 minutes or less, obsessive-compulsive personality disorder, other dissociative and conversion disorders, dissociative identity disorder, anxiety disorder, and major depressive disorder. The resident’s MDS dated 10/2/2025 showed a BIMS score of 7, indicating moderate cognitive impairment, and Section GG showed substantial assistance was needed for bathing, transfers, and bed mobility, with eating requiring setup only. Record review showed only two provider visit notes from a primary care physician, dated 9/30/2025 and 10/3/2025. All other documented provider visits from 1/17/2025 through 1/20/2026 were by APRNs, a DPM, a PA-C, and Hospice RN staff, with several later entries listed as unidentified signatures without a name or title. The resident was readmitted to hospice on 11/4/2025. During interview on 1/29/2026, the Administrator confirmed the facility could not provide physician visit notes for the dates reviewed and stated the facility had been following a 2024 CMS guideline that separated Medicare A and Medicaid provider visits by payer source, while also acknowledging that federal regulation does not separate provider visits by payer source and that existing physicians were overwhelmed with patients.
Failure to Document Provider Response to Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that the medical provider reviewed and documented what, if any, actions were taken in response to pharmacist recommendations made during the monthly drug regimen review for 2 of 5 sampled residents, Residents 6 and 13. Facility policies stated that the physician and staff would adjust existing medications based on efficacy and continued presence of relevant conditions and risks, and that staff and the practitioner would periodically review the continued relevance of each resident's medications. For Resident 13, the pharmacist documented multiple recommendations in pharmacy consultant progress notes asking whether PRN Zofran and PRN Benzonatate could be discontinued if they had not been used in the prior 90 days. The resident's electronic medical record contained no evidence that the provider reviewed these recommendations or documented any action taken. For Resident 6, who had diagnoses including head injury, traumatic brain injury, anxiety disorder, major depressive disorder, obsessive-compulsive personality disorder, dissociative disorders, and a BIMS score of 7 indicating moderate cognitive impairment, the care plan included psychiatric consultation and medication review if needed, as well as psychotropic medication concerns. The record review stated there was no physician review or note addressing pharmacy recommendations for medication changes.
Failure to Submit Timely Investigation Report for Suspected Neglect
Penalty
Summary
The facility failed to submit its investigation to the state agency within the required 5 working days for Resident 6, who was found at 6:00 AM on 1/2/26 wearing an overly wet and soiled brief. The incident was documented as suspected neglect involving Nurse Aide-A from the prior shift, who was suspected of leaving the resident in the soiled brief for an extended period. Resident 6’s record showed diagnoses of pancreatic cancer, rhabdomyolysis, diabetes mellitus type 2, and a traumatic brain injury. Facility records included an initial report to the state agency on 1/2/26 and an undated summary of findings investigation report, and the facility policy required the administrator to provide a follow-up investigation report within 5 business days. An email exchange from the Administrator confirmed that the final investigation report was not submitted to the state agency within the required timeframe, and the Administrator confirmed this in an interview on 1/28/2026 at 3:30 PM.
Delayed Incontinence Care and Missed Ordered Lab Work
Penalty
Summary
The facility failed to provide peri-care and incontinence care to a resident with urinary tract infection, mood disorder, paralytic syndrome with generalized muscle weakness, neurogenic bowel, and diabetes mellitus type 2. The resident reported being left waiting on prior occasions after staff said they would return with a second staff member needed for mechanical lift assistance, and stated they had waited 30 minutes to 2 hours for continence products to be removed and changed. The resident said this made them feel helpless and like they were inconveniencing staff. During observation, the resident told staff they needed to be changed and returned to their room, then turned on the call light. One nurse aide entered the room and left, and the resident remained waiting for assistance. The resident later stated they had asked two nurse aides for help but both said a second person was needed for the lift. The resident continued waiting while other staff used the mechanical lift in another room nearby, and later wheeled themselves into the hallway to seek help because they had a meeting at 10:00 AM. Two nurse aides eventually entered the room with the mechanical lift, and the resident was observed leaving the room after the care was completed. A nurse aide confirmed the resident had an incontinent bowel movement, and the DON stated staff are expected to assist toileting needs within approximately 10 to 15 minutes. The facility also failed to ensure ordered lab work was obtained for another resident with a history of hypertension, CKD stage 3, urinary incontinence, UTIs, heart failure, anemia, non-Alzheimer's dementia, and hypokalemia. The resident's care plan included obtaining and monitoring lab and diagnostic work as ordered, and the resident had new orders for a BMP and Hgb A1c. A progress note stated there were no tubes available for the lab draw, and an LPN confirmed the labs were not done and there was no progress note showing the MD was notified that the lab order was not completed.
Failure to Prevent Worsening Sacral Pressure Injury
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing occurred for a resident admitted with traumatic brain injury, dementia, COPD, and CHF. The resident had a coccyx skin issue identified as a peeling area/small open area on 12/11/25, and staff were educated to apply barrier cream with each brief change and reduce pressure to the buttocks while in bed. The area then split open on 12/15/25 and continued to be monitored over time, with measurements documented on 12/20/25 and 12/25/25, but the wound later showed purulent drainage on 12/31/25 and redness with minimal drainage on 1/8/26. By 1/15/26, the wound was documented as grey and light pink, 1.5 in long by 0.5 in wide and 0.5 cm deep, but no progress notes were charted from 1/16/26 through 1/19/26. On 1/20/26, the dressing change revealed green/brown drainage with foul odor, darker coloration, and surrounding redness. The provider was notified, a wound clinic referral was made, and the resident was placed on a q2h turning schedule for nurse aide documentation. On 1/21/26, the wound measured 5.5 by 3 by 1 with a large amount of purulent drainage, peeling skin, and foul odor. Additional skin integrity issues were documented on 1/22/26 involving the soles of the feet, left scapula, and right heel, and the wound clinic NP evaluated the resident on 1/23/26. The NP documented a saturated lower sacral dressing, foul odor, eschar, liquefied subcutaneous tissue, undermining, and estimated the wound at 5 cm long by 2 cm deep and 2 cm wide, describing it as a sacral pressure injury effectively Stage 4 and heavily draining and deeply infected. The NP recommended hospital transfer, and the resident was sent to the ED and later admitted for IV antibiotics and a surgical consult. The DON stated there were no additional interventions besides repositioning and wound dressing changes.
Failure to Employ Qualified Dietitian or Certified Food Service Director
Penalty
Summary
The facility failed to employ a full-time Registered Dietitian or have a certified Food Service Director, which had the potential to affect all 27 residents who consumed meals prepared in the kitchen. The facility's assessment identified the need for a qualified dietitian or clinically qualified nutrition professional to oversee the food and nutrition services. An interview with the Kitchen Supervisor revealed that they had been in the role for several months without completing any special certifications and were not a certified Food Service Director. Additionally, an interview with the Administrator confirmed that the dietitian had resigned and was no longer employed at the facility as of November 29, 2024.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to properly store, label, cover, and manage food and drink items, which could potentially lead to foodborne illness affecting all 27 residents. During an initial kitchen tour, several issues were observed: a half-full container of garlic in water was covered with foil and inadequately labeled; an unlabeled package of ground meat-like substance was found; a ziplock bag of loose raw meat-like substance was improperly labeled; and a tray with bags of diced meat sitting in liquid was incorrectly stored. Additionally, an opened container of cooking wine was past its best-if-used-by date, and a commercial coffee maker had uncovered carafes located next to a sink used for washing dirty dishes. A snack cart contained half-sandwiches in baggies with outdated labels. The Kitchen Supervisor was unaware of the requirement for coffee carafes to be covered and confirmed that the listed items should have been properly sealed, labeled, used, or discarded, and that bagged meats should not have been stored together in liquid.
Inadequate Infection Control in Laundry Handling
Penalty
Summary
The facility failed to handle contaminated linens in a manner that prevented potential cross-contamination and did not complete hand hygiene between distributing laundry for several residents. During an observation, a housekeeping/laundry staff member was seen distributing personal laundry to residents without performing hand hygiene between rooms. The staff member confirmed in an interview that they were unaware of the requirement to perform hand hygiene during the distribution of resident laundry. Additionally, the facility's policy on sorting soiled linen required employees to wear a gown and gloves. However, the housekeeping/laundry staff member stated that only gloves were worn during the sorting process, and no gowns were used. An observation of the laundry area revealed the presence of disposable exam gloves but no gowns, which was confirmed by the Administrator during an interview.
Failure to Provide Abuse Training During Orientation
Penalty
Summary
The facility failed to ensure that a nurse aide (NA-F) completed initial orientation with training on abuse, which had the potential to affect all 27 residents in the facility. A review of the facility's policy on Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised in April 2021, indicated that staff orientation should include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. However, during an interview, NA-F was unable to verbalize any types of abuse or identify when and whom to report to, despite being employed since October 2024. The Administrator confirmed there was no evidence that NA-F had completed the required abuse training during initial orientation.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for five residents, as required by their policy. The policy mandates that a baseline care plan be developed for each resident within 48 hours of admission and that a copy of the summary be provided to the resident or their representative. However, record reviews revealed that no baseline care plans were developed for Residents 13, 16, and 22. For Residents 15 and 20, the baseline care plans were completed more than 48 hours after admission, and there was no evidence that copies were provided to the residents or their representatives. Interviews with the Director of Nursing (DON) confirmed the deficiencies, as the DON was unaware of the requirement to develop and implement baseline care plans within 48 hours and stated that the facility had never provided copies of the baseline care plans to residents or their representatives. The residents involved had various medical conditions, including dementia, Alzheimer's disease, chronic pain, and kidney disease, which necessitated timely and appropriate care planning to address their immediate needs upon admission.
Inadequate Supervision and Intervention for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to protect four residents from the adverse behaviors of another resident, identified as Resident 15, who was admitted with severe cognitive impairment and a history of wandering and aggression. Despite being aware of Resident 15's tendency to enter other residents' rooms and engage in altercations, the facility's interventions were inadequate and often duplicated, failing to prevent further incidents. Resident 15 was involved in multiple altercations with other residents, resulting in physical aggression and injuries, such as bruises and skin tears. The facility's care plan for Resident 15 included interventions like increased monitoring and redirection, but these measures were insufficient and inconsistently applied. The Director of Nursing confirmed that no new interventions were implemented after certain altercations, and some interventions were merely duplicates of previous ones. This lack of effective intervention and supervision led to repeated incidents of resident-to-resident altercations, highlighting a deficiency in the facility's ability to provide a safe environment for its residents.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged misappropriation of resident property to the state agency within the required 24-hour timeframe and did not submit an investigation report within 5 working days. The incident involved a resident who alleged that someone had stolen 4 million dollars from them. The facility's policy, last revised in September 2022, mandates that any suspicion of misappropriation must be reported immediately, defined as within 24 hours, to the administrator and other officials according to state law. The deficiency was identified through interviews and record reviews. On August 7, 2024, the dialysis center informed the facility about the resident's allegation. However, the facility did not notify Adult Protective Services (APS) until August 13, 2024, and the investigation report was submitted to the state agency on August 19, 2024. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the delay in reporting and submission of the investigation, which did not comply with the facility's policy and state requirements.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Sets (MDS) for two residents, leading to discrepancies in the documentation of active diagnoses, medication use, and Gradual Dose Reduction (GDR) information. For Resident 9, the annual MDS inaccurately indicated the use of an anticoagulant, while the resident was actually taking an antiplatelet medication, clopidogrel. Additionally, the MDS did not document that a GDR for Zyprexa, an antipsychotic medication, was clinically contraindicated, despite this being noted in the resident's Medication Risk Benefit Evaluation. For Resident 17, the quarterly MDS incorrectly listed septicemia as an active diagnosis, although there were no indications of ongoing septicemia since before the resident's admission. An interview with the MDS-Registered Nurse confirmed these inaccuracies, acknowledging that Resident 9's MDS should have reflected the use of an antiplatelet and the contraindicated GDR, and that Resident 17's MDS should not have included septicemia as an active diagnosis.
Failure to Provide Complete Discharge Summary
Penalty
Summary
The facility failed to develop and provide a discharge summary that included a recapitulation of stay for a resident who was discharged. The facility's policy, revised in October 2022, mandates that the discharge summary should include a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. Additionally, a copy of the evaluation of the resident's discharge needs, the post-discharge plan, and the discharge summary should be provided to the resident and filed in their medical record. However, upon reviewing the discharge planning document dated 10/7/2024, it was found that the section for the recap of the resident's stay was left blank. This was confirmed in an interview with the Director of Nursing, who acknowledged that the recapitulation of stay was not completed or provided to the resident.
Deficiency in Antibiotic Stewardship for a Resident
Penalty
Summary
The facility failed to ensure that the drug regimen for a resident was free from unnecessary drugs, specifically regarding the use of prophylactic antibiotics. A review of the facility's policy on Antibiotic Stewardship indicated that complete antibiotic orders should include the drug name, dose, frequency, duration of treatment, route, and indication. However, a review of Resident 2's Order Summary revealed that the orders for Macrobid and bacitracin-polymyxin ophthalmic ointment lacked stop dates or durations. Additionally, the antibiotic eye drops did not have a valid indication for use. An interview with the Director of Nursing confirmed these deficiencies in the antibiotic orders for Resident 2.
Failure to Maintain Nutritive Value of Pureed Food
Penalty
Summary
The facility failed to maintain the nutritive value of pureed food, affecting two residents. During a meal service observation, Cook-A was seen preparing pureed meals by blending chicken and dumplings, seasoned peas, and cornbread with an electric blender. Unmeasured hot water from a coffee carafe was added to each food item to achieve the desired consistency, which was then served to the residents along with cooked canned sweet potatoes. A review of the facility's recipe for Chicken and Dumplings showed no guidance for mechanical soft or pureed diet modifications, and no recipes were available for the peas or cornbread. Interviews revealed that Cook-A prepared and served the pureed food to the two residents, and the Kitchen Supervisor was unaware that adding water could decrease the nutritive value of the food. The Administrator confirmed the absence of a facility policy for preparing mechanically altered texture foods for residents.
Failure to Serve Food in Ordered Texture
Penalty
Summary
The facility failed to provide food in the texture ordered by the medical provider for two residents, identified as Residents 5 and 15. Resident 5 had an active physician's order for a regular diet with mechanical soft texture and thin consistency liquids, while Resident 15 had an order for a liberalized diet with mechanical soft texture and regular consistency liquids. During an observation of meal service, it was noted that Cook-A prepared and served pureed food to both residents, despite their orders for mechanical soft diets. The cook blended chicken and dumplings, peas, and cornbread into a pureed consistency, which was not in accordance with the dietary orders. The facility lacked a policy for preparing modified texture foods, and the Nursing Home Administrator was unaware that the foods were being served at a different consistency than what was ordered. The facility's documents indicated that chicken and dumplings should be served as a ground texture, peas as pureed, and cornbread as a slurry for residents on a mechanical soft diet. However, the preparation observed did not align with these guidelines, leading to the deficiency in serving food in the correct texture as ordered by the medical provider.
Failure to Conduct Nurse Aide Registry Checks
Penalty
Summary
The facility failed to conduct required nurse aide registry checks for adverse findings for four out of five sampled employees, which could potentially affect all 27 residents within the facility. The facility's policy, revised in April 2021, mandates conducting employee background checks, including state nurse aide registry checks for any adverse findings. However, a review of personnel files revealed that no nurse aide registry checks were completed for a cook, an LPN, and two nurse aides hired between August and October 2024. This was confirmed in an interview with the Administrator, who acknowledged the oversight in conducting these checks.
Inaccurate Reporting of Resident Elopement Incident
Penalty
Summary
The facility failed to submit an accurate investigation report to the state agency following the elopement of a resident. The Director of Nursing (DON) submitted a report that contained several inconsistencies regarding the dates and times of the incident and notifications. The report inaccurately stated that the elopement occurred on a different date than it actually did, and it also provided incorrect times for when the Adult Protective Services (APS) and the facility administrator were notified. Additionally, the report misstated the time the resident returned to the facility with the DON. These discrepancies were confirmed during an interview with the DON, highlighting a failure in accurately documenting and reporting the incident.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement adequate interventions to prevent elopements for a resident identified as at risk for wandering and elopement. The resident, who had severe cognitive impairment and a history of wandering, was initially residing in the Memory Care Unit (MCU) but was moved to a non-locked unit after the facility determined they were not at risk for elopement. Despite this, the resident continued to exhibit behaviors indicating a risk for elopement, such as making statements about leaving the facility and asking staff for help to leave. The resident's care plan included interventions like exit alarms, behavior logs, and personalization of their room, but these were not sufficient to prevent an elopement incident. On one occasion, the resident was found outside the facility in a park, indicating a failure in the supervision and interventions in place. Following this incident, the facility implemented 15-minute safety checks, which were later reduced to hourly checks and eventually discontinued, despite the resident's continued risk behaviors. Interviews with facility staff, including the Director of Nursing, revealed that the facility did not have a comprehensive plan to prevent further elopements after the initial incident. The care plan was updated to include a focus on elopement only after the resident had already eloped, and the interventions in place were not sufficient to prevent the resident from leaving the facility again. This lack of proactive measures and adequate supervision contributed to the deficiency identified in the report.
Failure to Notify Resident's Representative of Significant Weight Loss
Penalty
Summary
The facility failed to notify the resident's representative of a significant change in condition for one of the sampled residents. The resident, who was admitted with a principal diagnosis of acute and chronic respiratory failure with hypoxia, experienced a 7.4% weight loss over one month. Despite the facility's policy requiring notification of significant changes in a resident's condition, there was no documentation that the resident's Power of Attorney (POA) had been informed of this weight loss. The resident's care plan included monitoring for signs of dehydration and malnutrition, which listed significant weight loss as a key indicator. However, the weight changes were documented in the electronic health record system without any corresponding notification to the POA or primary care provider (PCP). Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), revealed that the weight loss was not noticed or reported as required. The LPN did not recall noticing the weight change, and the DON confirmed that such a significant weight loss should have been reported to the resident's POA and PCP. The DON also stated that they had not been made aware of the weight loss and, therefore, had not taken the necessary steps to monitor the resident or notify the appropriate parties. This failure to communicate a significant change in the resident's condition constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Assist Dependent Resident with Toileting
Penalty
Summary
The facility failed to assist a dependent resident with toileting, as evidenced by multiple observations and interviews. Resident 2, who was admitted with diagnoses including left side hemiplegia, paraplegia, epilepsy, Spina Bifida, and muscle weakness, required total assistance for all Activities of Daily Living (ADLs) according to their Care Plan. On 3/26/2024, Resident 2 reported to an LPN that Nurse Aides had entered the room, shut off the call light, and left without providing assistance for toileting. Despite the LPN's acknowledgment, no staff provided the necessary assistance from 11:57 AM to 12:25 PM. Resident 2 later confirmed that it was common for staff to shut off the call light without offering help. Interviews with staff, including a Nurse Aide and the Director of Nursing (DON), confirmed that Resident 2 was dependent for all care and that the facility's policy required timely response to call lights and adherence to care plans for toileting assistance. The facility's policy on Activities of Daily Living (ADLs), last revised in March 2018, mandates that appropriate care and services be provided to dependent residents in accordance with their care plans, including toileting. The policy also states that staff should not assume residents are refusing care if they resist. Despite these guidelines, the facility failed to meet the care needs of Resident 2, as evidenced by the lack of timely assistance and the common practice of shutting off call lights without providing the required help. This deficiency was identified through record reviews, observations, and interviews with the resident and staff.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify a significant weight loss for one resident, leading to a deficiency in providing adequate food and fluids to maintain the resident's health. The resident experienced a 7.4% weight loss over one month, which was not properly documented or addressed by the facility staff. The facility's policy required that any weight change of 5% or more be retaken the next day for confirmation and that the dietitian be notified immediately. However, this procedure was not followed, and the resident's significant weight loss went unreported to the dietitian, primary care provider (PCP), and the resident's power of attorney (POA). Additionally, there was no documentation of the resident's fluid or meal intake for the prior 30 days in the electronic health record (EHR), despite the resident frequently refusing meals and showing signs of decreased appetite and malnutrition. The resident's care plan included monitoring for signs of dehydration and malnutrition, such as significant weight loss, but these signs were not adequately documented or reported by the staff. Interviews with nursing aides and licensed practical nurses (LPNs) revealed that the resident's weights were obtained and given to the nurse on duty, but there was no clear process for reviewing and acting on significant weight changes. The Director of Nursing (DON) confirmed that a significant weight loss should be considered a change in condition and reported to the PCP and POA, but this did not occur for the resident in question. The DON also stated that the facility's electronic health record system should flag significant weight changes, but this warning was not observed for the resident. The resident had a history of declining meals and requesting only desserts in the evenings, which was known to the staff. Despite this, there was no consistent documentation of the resident's meal refusals, alternative food offerings, or the provision of high-calorie supplements. The resident was eventually sent to the emergency room for evaluation, where they were diagnosed with diverticulitis and dehydration. The lack of proper documentation and communication regarding the resident's weight loss and nutritional intake contributed to the deficiency in maintaining the resident's health through adequate food and fluids.
Medication Dosage Errors
Penalty
Summary
The facility failed to prepare and administer the correct dosage of medication for two residents, resulting in a medication error rate of 7.69%. An observation revealed that an LPN prepared an unmeasured amount of Diclofenac Gel 1% for Resident 8, despite the order specifying 2 grams to be applied to both knees. The LPN admitted to not knowing how to measure the gel. Additionally, the same LPN administered 17 grams of Miralax to Resident 12 instead of the ordered 2 tablespoons. The facility's policy on administering medications, which includes verifying the right medication, dosage, time, and method, was not followed. The facility had a census of 27 residents at the time of the survey.
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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 Hemingford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Park Care Center | 17.9 mi | ★★★★★ | 0 | 0 |
| Ponderosa Villa | 30.4 mi | ★★★★★ | 9 | 0 |
| Pioneer Manor Nursing Home | 32.2 mi | ★★★★★ | 4 | 0 |
| Crest View Care Center | 36.3 mi | ★★★★★ | 19 | 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.