Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Hemphill Care Center during CMS and state inspections, most recent first.
A resident with a fractured lower leg, impaired cognition, and documented pressure ulcer risk did not have a comprehensive care plan that addressed the splint on the lower extremity or the risk for skin breakdown. The resident later developed a left heel pressure injury, and records showed the care plan had not included the identified risk factors or the actual wound.
Failure to Document Splint-Related Pressure Injury Prevention and Heel DTI: A resident admitted with a left ankle fracture and splint was identified as being at risk for pressure ulcers, but the admission assessment, skin assessment, care plan, and order summary did not document the splint or related interventions. Staff later found a DTI to the left heel, and wound documentation showed the area progressed to a pressure injury with skin prep and offloading orders. Interviews confirmed the splint should have been documented and that device-related pressure injury prevention measures were not in place.
Improper Vaccine Refrigerator Temperature Monitoring: The facility failed to store vaccines in accordance with accepted professional principles when injectable influenza vaccines were kept in the medication room refrigerator and the temperature was logged only once daily instead of twice daily as required for vaccine storage. An LVN stated staff checked the refrigerator once a day, the log showed one daily temperature entry, and the ADON and DON acknowledged the monitoring did not meet standards of care.
A facility failed to maintain an effective infection prevention and control program, as evidenced by mishandling a foley catheter drainage bag and improper hand hygiene during mealtime assistance. A CNA and LVN placed a catheter bag on the floor, unaware of infection risks, while an RA did not sanitize hands between assisting two residents, despite knowing the potential for cross-contamination. These actions violated the facility's infection control policies, posing a risk to residents with significant medical conditions.
A resident with quadriplegia and dysphagia was fed by a contract staff member who stood rather than sitting at eye level, contrary to facility policy. The staff member was unaware of the requirement to sit while feeding, highlighting a training gap for contract staff. The facility's policy emphasizes treating residents with dignity and respect.
A facility failed to maintain a safe environment by not properly inspecting and removing worn Hoyer lift slings, placing a resident with quadriplegia at risk. Observations revealed faded and illegible slings in use, and staff were unaware of manufacturer guidelines for sling maintenance. The facility's policy required discarding worn slings, but this was not consistently followed, leading to the deficiency.
The facility failed to ensure that the emergency call light systems in the bathrooms of two residents with severe cognitive impairments were functional and accessible. The call light cords were not long enough to be reachable from the floor, potentially preventing residents from calling for assistance. Staff interviews revealed that there was a process for reporting maintenance issues, but the deficiency persisted, indicating a lapse in timely resolution.
The facility did not post nurse staffing information in a prominent location accessible to residents and visitors on two reviewed days. The postings were placed on a bulletin board by the Administrator's office and time clock, not at the front entrance as required. Interviews revealed that the DON was unaware of the need for visibility, and the issue was only addressed after being identified.
The facility failed to have a licensed administrator, with the Assistant Administrator acting in the role without an active license. The Regional Director of Operations was not consistently present, and the Assistant Administrator had not passed the necessary exams. This led to confusion among staff about who was responsible for administrative duties.
A resident's rights were violated when a male CNA forcibly assisted her during a shower, despite her objections. The resident, who was experiencing weakness and confusion, felt humiliated and distressed by the CNA's actions. The CNA had a history of similar complaints and was terminated following an investigation.
A resident with moderately impaired cognition was verbally, physically, and mentally abused by a CNA during a showering session, despite expressing a desire to shower independently. The CNA, who had a history of similar allegations, forcibly removed the resident's clothing and disregarded her requests to stop, leading to feelings of humiliation and intimidation. Multiple residents and staff reported the CNA's inappropriate behavior, resulting in the CNA's termination.
A resident with cognitive impairment accessed a staff breakroom, took car keys, and drove off the premises. The facility failed to report the incident, complete an incident report, or notify the resident's physician. Personal items were stored in areas accessible to residents, and there was a lack of consistent monitoring and supervision.
The facility failed to notify responsible parties and physicians of incidents involving two residents, leading to delayed treatment and family grievances. One resident experienced a fall resulting in a compression deformity, while another sustained a bruise to the eye during care. Staff admitted to not following notification protocols.
Incomplete Care Plan for Pressure Injury Risk and Heel Breakdown
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident that included measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs. Resident #1 was an older female admitted with a diagnosis of fracture to the left lower leg. Her admission MDS showed a BIMS of 10, indicating moderately impaired cognition, and a Braden Scale assessment identified her as at risk for pressure ulcers. The comprehensive care plan dated 8/20/2025 did not address her pressure ulcer risk or the presence of a splint to the left ankle, even though the CAA trigger report indicated a care plan was needed for pressure ulcer risks. Record review showed that Resident #1 had limited range of motion to the left leg and a splint in place to the left lower extremity, and later developed skin breakdown to the left heel. On 8/28/2025, an order was entered to apply skin prep to an unstageable area on the left heel every shift until resolved or treatment changed. Subsequent skin assessments documented a deep tissue injury and black discoloration with skin intact to the left heel, and a wound care note described a pressure injury measuring 3 cm x 2.4 cm with instructions to apply skin prep and offload the wound. Interviews with the LVN, DON, and Administrator confirmed that the comprehensive care plan should have addressed the splint, skin breakdown risk, and actual heel breakdown, but these items were not identified in the care plan.
Failure to Document Splint-Related Pressure Injury Prevention and Heel DTI
Penalty
Summary
The facility failed to ensure necessary treatment and services were provided to promote healing and prevent new pressure injuries for a resident admitted with a left lower leg fracture and a left ankle splint. On admission, the resident was identified as being at risk for pressure ulcers based on the MDS and Braden Scale, but the comprehensive care plan did not address the pressure injury risk or the presence of the splint. The consolidated order summary also did not include any orders related to the left ankle splint, and the admission assessment and skin assessment did not document the splint or any device-related interventions. Record review showed the resident had a left ankle splint in place from the hospital, and later notes continued to reference the splint on the left lower extremity. The facility did not have documented orders or interventions in place related to the splint at admission. Staff interviews indicated the resident was told to keep the splint in place until orthopedic follow-up, but the admitting nurse stated she forgot to chart the splint and orders in a progress note once the resident was entered into the charting system. The DON and ADON stated the splint should have been documented and that measures should have been in place because devices can contribute to pressure injuries. The resident later developed a deep tissue injury to the left heel. A skin assessment documented black discoloration with intact skin to the left heel, and subsequent wound care documentation described a pressure injury measuring 3 cm by 2.4 cm with orders for skin prep and offloading. The wound care doctor’s initial note did not assess the heel injury on the first visit after it was identified, and staff interviews reflected uncertainty about when the wound was first addressed. The ADON stated the resident had a nonremovable splint on admission and that when the splint was removed, the resident had a deep tissue injury to the left heel and redness to the side of the foot.
Improper Vaccine Refrigerator Temperature Monitoring
Penalty
Summary
Drugs and biologicals used in the facility were not stored in accordance with currently accepted professional principles, and the facility did not include the appropriate accessory and cautionary instructions and expiration date when applicable for 1 of 1 vaccine/medication storage refrigerators reviewed. During an observation and interview on 9/23/2025 at 8:45 AM, 5 packages of ten injectable influenza vaccines were observed inside the medication room refrigerator. LVN B stated that staff checked and logged the refrigerator once a day and checked the temperature to make sure it stayed between 35 and 40 degrees. Record review of the September 2025 medication refrigerator log showed the refrigerator was monitored daily and temperatures were documented one time each day from September 1, 2025, until September 22, 2025, with readings within perimeters of 36 to 46 degrees Fahrenheit. During interviews, the ADON stated the facility had not been checking or logging temperatures as required by standards of care, and the DON stated she was not aware the temperature should be checked and logged twice daily when vaccines were stored in the refrigerator. The facility policy titled Medication Storage in the Facility stated the refrigerator or freezer in which vaccines are stored should be checked at least two times a day per CDC guidelines, and the CDC guidance reviewed stated storage unit temperatures should be checked and recorded at least 2 times a day if min/max temperatures are not displayed.
Infection Control Lapses in Catheter Handling and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving staff members and residents. In the first incident, a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN) were observed mishandling a foley catheter drainage bag for a resident with chronic kidney disease and urinary retention. During a transfer, the CNA placed the drainage bag on the floor, and after the transfer, the bag was hung on the side of the bed with the bottom still touching the floor. Both staff members were unaware of the infection control implications of this action, despite having been trained on catheter care and infection control. In the second incident, a Resident Assistant (RA) failed to perform proper hand hygiene while assisting two residents during mealtime. The RA did not wash or sanitize her hands between assisting a resident with quadriplegia and another resident with Alzheimer's Disease. This lapse in hand hygiene occurred despite the RA's awareness of the potential risk for bacteria or viruses due to improper hand sanitation. The facility's policies clearly indicate the importance of hand hygiene to prevent the spread of infections. These deficiencies were identified through observations, interviews, and record reviews, highlighting the facility's failure to adhere to its own infection control policies. The incidents involved residents with significant medical conditions, such as chronic kidney disease, quadriplegia, and Alzheimer's Disease, who were dependent on staff for daily living activities. The lack of adherence to infection control protocols posed a risk of cross-contamination and infection among the residents.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during mealtime assistance. Resident #27, who has quadriplegia and dysphagia, was observed being fed by RA C while she stood, rather than sitting at eye level as required by facility policy. The resident, who is dependent on staff for all activities of daily living, did not express discomfort with the standing position, but the facility's policy and standard practice dictate that staff should be seated to maintain dignity and respect during feeding. RA C, a contract staff member from the therapy department, had been employed for six months and was not aware of the requirement to sit while feeding residents. She mentioned that standing was more comfortable for her due to hip issues and had not received specific training on this aspect of resident care. Interviews with the ADON and DON confirmed that staff should be seated at eye level when assisting residents with meals, and the incident highlighted a gap in training for contract staff. The facility's policy from 2001 emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in this instance.
Failure to Maintain Safe Environment with Hoyer Lift Slings
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards for a resident with quadriplegia and intracranial injury, who was dependent on staff for transfers. The deficiency was identified when a resident was observed sitting in a Geri-chair with a lift sling that had faded straps and illegible care tags, indicating wear and potential compromise. Additionally, a CNA was unaware of the manufacturer's guidelines for removing slings with changes in color or illegible labels, which could indicate they were worn or compromised. The CNA admitted to using slings from the linen storage closet without proper inspection, which could place residents at risk of injury during transfers. Further observations revealed that the facility's staff, including the DON and laundry staff, were not fully aware of the manufacturer's recommendations for sling maintenance, such as removing slings with signs of wear, color fading, or illegible labels. The facility's policy required slings to be discarded if worn, frayed, or ripped, but this was not consistently followed. The administrator confirmed that slings should be inspected for wear and tear before use, but the lack of adherence to these guidelines led to the deficiency, potentially endangering residents during mechanical lift transfers.
Inaccessible Call Light Systems in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the emergency call light systems in the bathrooms of two residents were functional and accessible. Specifically, the call light cords in the bathrooms of Resident #11 and Resident #21 were not long enough to be reachable from the floor, which could prevent residents from calling for assistance if needed. Both residents had severe cognitive impairments due to Alzheimer's Disease and required substantial assistance with toileting. Observations revealed that the call light cords were either too short or missing, which was confirmed during interviews with staff members. Interviews with the facility's staff, including a CNA, the Administrator, and the maintenance supervisor, indicated that there was a process in place for reporting and addressing maintenance issues, including call light deficiencies. However, the deficiency persisted, as evidenced by the short call light cords in the residents' bathrooms. The facility's policy required that call lights be within easy reach of residents, and any defective call lights should be reported promptly. Despite these procedures, the issue was not resolved in a timely manner, potentially delaying the residents' ability to receive necessary assistance.
Failure to Post Nurse Staffing Information Prominently
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily in a prominent and accessible location for residents and visitors on two of the three days reviewed. On 8/12/2024 and 8/13/2024, the staffing information was not displayed at the front entrance or at the nurse station, but rather on a bulletin board down P-hall by the Administrator's office and the time clock, which was not easily visible to all residents and visitors. This oversight was observed during specific times on both days, and although the postings contained all necessary information, their location did not comply with the requirement for visibility. Interviews with facility staff revealed a lack of awareness regarding the proper location for posting staffing information. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were responsible for preparing and posting the staffing data, respectively. The DON, who had been in her position since April 2024, was unaware that the postings needed to be in a location visible to everyone entering the facility. The Regional Nurse and the Administrator confirmed that the postings should be at the front entrance, but this practice was not followed until after the issue was identified. The facility's policy, revised in July 2016, clearly stated that staffing numbers should be posted in a prominent location within two hours of each shift's start.
Facility Lacks Licensed Administrator
Penalty
Summary
The facility failed to ensure that it had a licensed administrator responsible for managing the facility, as required by state regulations. The Assistant Administrator, who was acting as the facility's administrator, did not possess an active Texas Administrator license. This situation arose when the previous administrator left, and the Assistant Administrator continued in the role without the necessary licensure, under the assumption that the Regional Director of Operations was the licensed administrator by proxy. Interviews with various staff members, including the ADON, DON, and the Assistant Administrator, revealed confusion and miscommunication regarding who was the licensed administrator. The Assistant Administrator admitted to not having passed the necessary exams to obtain her administrator's license and acknowledged that the facility had been without a full-time licensed administrator for eight months. The Regional Director of Operations, who was supposed to be the licensed administrator, was not consistently present at the facility and was using his license at other sister facilities. Record reviews showed that the Assistant Administrator was hired with the expectation of becoming the administrator upon passing her exams. However, she had been signing off as the administrator in Quality Assurance and Performance Improvement meetings, despite not having the required license. The facility's policy clearly stated that a licensed administrator must manage the day-to-day functions, but this was not adhered to, leading to the deficiency.
Resident Rights Violation During Shower Incident
Penalty
Summary
The facility failed to ensure that a resident's right to be treated with respect and dignity was upheld during a shower incident involving a CNA. The resident, who had a history of being independent in showering, was reportedly forced to accept assistance from a male CNA despite expressing discomfort and a desire to shower alone. The resident, who was experiencing weakness and confusion due to low blood sugar and a UTI, was reportedly manhandled by the CNA, who ignored her requests to stop and used forceful methods during the shower. The incident was compounded by the CNA's history of similar allegations and complaints from other residents about his rough and disrespectful behavior. Multiple residents and staff members reported that the CNA had been rude, arrogant, and had engaged in inappropriate conduct, including making derogatory remarks and being rough during care. Despite previous complaints and warnings, the CNA continued to exhibit behavior that violated residents' rights and dignity. The facility's investigation into the incident revealed that the CNA had a pattern of behavior that was detrimental to the welfare of residents. The resident involved in the incident felt humiliated and distressed, and the situation was reported to the state. The facility ultimately terminated the CNA's employment following the investigation, acknowledging the failure to protect the resident's rights and dignity.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to ensure the right of a resident to be free from abuse and neglect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) identified as CNA A. The incident occurred during a showering session where the resident, who had a history of being independent in showers, was forced to receive assistance from CNA A despite expressing a desire to shower independently. The resident, who had moderately impaired cognition and was experiencing weakness and confusion due to low blood sugar and a urinary tract infection, was reportedly verbally, physically, and mentally abused by CNA A. The resident expressed feeling humiliated and intimidated during the incident, which involved CNA A forcibly removing the resident's clothing and disregarding her requests to stop. The report indicates that CNA A had a history of similar allegations and had been previously warned and trained on proper shower techniques and sensitivity. Despite this, CNA A continued to exhibit inappropriate behavior, including rough handling and verbal abuse, as reported by multiple residents and staff members. Witnesses described CNA A as rude, arrogant, and unprofessional, with a tendency to engage in horseplay and make inappropriate comments. The facility's records show that CNA A had been involved in previous incidents of rough handling and verbal abuse, which were addressed through in-service training and written warnings. The facility's investigation into the incident with the resident was inconclusive, but the decision was made to terminate CNA A due to the repeated nature of the allegations and the potential risk to residents. The report highlights the failure of the facility to adequately address and prevent the abusive behavior of CNA A, despite previous complaints and interventions. The resident involved in the incident expressed ongoing distress and fear as a result of the experience, indicating a significant impact on her emotional well-being.
Resident Elopes and Takes Staff Car
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accident hazards for a resident who accessed the staff breakroom, obtained car keys, and drove off the premises. The resident, who had a history of cognitive impairment and various medical conditions, signed herself out of the facility and took a staff member's car without permission. The incident was not reported to the appropriate authorities, and the facility did not complete an incident report or notify the resident's physician. The resident's care plan included interventions to manage her cognitive impairment and agitation, but these measures were not sufficient to prevent her from accessing restricted areas and taking the car. Staff interviews revealed that personal items, including car keys, were stored in areas accessible to residents, and there was a lack of consistent monitoring and supervision. The ADON and other staff members were aware of the incident but did not consider it reportable, as the resident had signed herself out. The facility's policies on wandering, elopement, and notifying physicians of significant changes in resident status were not followed. The staff did not document the incident in the resident's medical record or complete an incident report. Additionally, the facility did not notify the resident's physician or other relevant authorities, despite the potential risks associated with the resident's actions. The lack of proper documentation and reporting highlights deficiencies in the facility's supervision and safety protocols.
Failure to Notify Responsible Parties and Physicians of Incidents
Penalty
Summary
The facility failed to immediately inform the responsible parties and physicians of two residents when significant incidents occurred. Resident #1, who had a history of falls and moderately impaired cognition, experienced a witnessed fall in her room. Despite the fall being documented, there was no notification to the resident's family or physician. The resident later complained of back pain, and an x-ray revealed a compression deformity in the lumbar spine, indicating a potential delay in treatment due to the lack of immediate notification. Resident #2, who had severely impaired cognition and was prone to bruising due to fragile skin, sustained a bruise to her right eye after hitting her face on the wall while being turned for incontinent care. The incident was not immediately reported to the resident's responsible party or physician. The family discovered the bruise during a visit and expressed concerns about the lack of notification and the potential for other unreported injuries. The ADON admitted to not notifying the family immediately because there was no visible injury at the time of the incident. Interviews with staff revealed inconsistencies in the notification process and a lack of adherence to the facility's policy on reporting incidents. The ADON and other staff members acknowledged the failure to notify the responsible parties and physicians promptly. This deficiency in communication placed the residents at risk of delayed treatment and compromised their well-being, as evidenced by the subsequent medical findings and family grievances.
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Illustrative
What surveyors actually found near you
We read the 24 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hemphill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacies Nursing And Rehabilitation | 1.7 mi | ★★★★★ | 5 | 0 |
| Avir At San Augustine | 19.1 mi | ★★★★★ | 4 | 0 |
| Stonecreek Nursing & Rehabilitation | 20.2 mi | ★★★★★ | 6 | 0 |
| Colonial Pines Healthcare Center | 21.1 mi | ★★★★★ | 9 | 0 |
| Toledo Retirement And Rehabilitation Center | 24.9 mi | — | 0 | 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.