Caleb Hitchcock Health Center

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #6) reviewed for hospitalization, the facility failed to ensure Resident #6 who exhibited self-injurious behaviors (biting, gnawing and sucking), had a comprehensive care plan developed and interventions implemented to minimize the risk of injury. The facility's failure to develop a comprehensive care plan with individualized interventions to address self-injurious behaviors resulting in the development of an open area, progressing to osteomyelitis (a bone infection) and gangrene which required a partial right third finger amputation. These failures resulted in the finding of immediate jeopardy. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #6) reviewed for hospitalization, the facility failed to protect the skin of a resident with known behaviors of picking and gnawing at his/her fingers, failed to monitor the fingers after gnawing caused skin deterioration of the finger, failed to document an assessment when the fingers were noted with breakdown which resulted in Resident #6 developing osteomyelitis (a bone infection),and gangrene requiring a partial right third finger amputation. These failures resulted in the finding of Immediate Jeopardy. [...]

Inspectors wroteBased on review of facility documentation, facility policy and interviews regarding the employment of an Infection Preventionist, the facility failed to designate an individual with the required training and certification to oversee the Infection Control Program.

Inspectors wroteBased on review of facility documentation, facility policy, and interviews regarding the facility Infection Control program, the facility failed to document Covid-19 staff effected on a line list, failed to document and complete Covid-19 testing per facility policy, and failed to provide facility-initiated education to non-nursing personnel related to Covid-19

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #1) reviewed for accidents, the facility failed to follow professional standards of practice for the monitoring of neurological assessments following an unwitnessed fall. Additionally, for 1 of 2 residents (Resident #6) reviewed for hospitalization, the facility failed to follow professional standards of practice regarding completing a skin assessment when Resident #6 was observed to sustain bloody areas to the fingers of the right hand caused by the behaviors of sucking, biting and picking and failed to ensure routine skin assessments were completed by a Registered Nurse (RN) and not a Licensed Practical Nurse (LPN).

Inspectors wroteBased on review of the clinical record, observations, interviews and facility policy for 1 of 3 sampled residents (Resident #12) reviewed for pressure ulcers, the facility failed to ensure the alternating pressure mattress was set correctly.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #4) reviewed for positioning and mobility, the facility failed to obtain a physician's order, develop a plan of care and provide staff education for a resident's lower extremity brace.

Inspectors wroteBased on observations, interviews, facility documentation and facility policy for 1 of 1 supply closets observed, the facility failed to ensure the nursing supply closet on the secured Memory Care unit was locked/secured. Review of the Resident Listing Report dated 11/18/25 indicated there were 12 residents living on the facility's secured Memory Care unit. An observation on the secured Memory Care unit on 11/18/25 at 10:30 AM identified the nursing supply closet was unlocked and contained 20 bottles of peri wash (8.1 ounces (oz) each), 24 bottles of non-alcohol mouthwash (4 oz each bottle), 22 bottles of body cream (5 oz in each bottle), 12 tubes of barrier cream, 25 bottles of body lotion (8 oz in each bottle). [...]

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure care was provided gently when staff repositioned Resident #1 and staff pulled on Resident #1's wrist to turn him/her in the bed.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an allegation of abuse timely.

Inspectors wroteBased on observation of the Dietary Department, staff interview, and facility policy, the facility failed to ensure cleanliness of the kitchen, a food items were labeled when opened, contained an expiration date, failed to failed to perform hand hygiene, and adequately store a chemical solution away from food.

Inspectors wroteBased on observations, review of facility policy and interview for 2 of 5 resident living units, the facility failed to ensure that all residents, except those assessed to require a secured unit, were allowed to freely move off the unit or about the facility resulting in the finding of a pattern of involuntary seclusion.

Inspectors wroteBased on observations, review of facility documentation, facility policy, and interviews, the facility failed to ensure laundry was handled in a clean manner.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 2 of 5 residents (Resident #6 and #19) reviewed for unnecessary medications, the facility failed to initiate a care plan for an anticoagulant (blood thinning) medication.

Inspectors wroteBased on review of the clinical record, facility policy and interviews for the only sampled resident (Resident #10) reviewed for hearing loss, the facility failed to review and revise the care plan when a hearing aid was unavailable.

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 2 of 2 residents (Resident #17 and Resident #36) reviewed for nutrition, for Resident #17 the facility failed to assess the resident's nutritional needs following a significant weight loss and for Resident #36, failed to follow a dietician's recommendation for nutritional supplements

Inspectors wroteBased on observations, facility documentation, and interviews for 11 of 11 residents (Resident #'s 1, 7, 16, 22, 27, 29, 42, 44, 46, 401, and 402) interviewed during the Resident Council meeting, the facility failed to ensure survey results were accessible to residents.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #63) reviewed for accidents, the facility failed to ensure timely notification of Resident #63's physician and responsible person when a change in skin integrity was identified.

Inspectors wroteBased on clinical record review, review of facility documentation and interviews for 1 of 4 sampled residents (Resident #263) reviewed for accidents, the facility failed to ensure a mechanical transfer was provided according to the plan of care.

Inspectors wroteBased on interviews, review of employee files, and facility policy for 3 of 3 Nurse Aides (NAs) reviewed (NA #4, NA #5, and NA #6), the facility failed to complete an annual performance appraisal for NA #4, NA #6 and failed to complete a 90 day evaluation for NA #5 per facility policy.

Inspectors wroteBased on review of the clinical record, facility documentation and staff interview for 5 residents (Residents #1, Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for resident assessment, the facility failed to ensure the Discharge assessment-return not anticipated MDS' were transmitted to the CMS System according to established timeframes.