Hemingford Care Center

Inspectors wroteLicensed Reference Number 175 12-006.05 (J) Based on observation, interview, and record review, the facility failed to give residents, family members, legal representatives of the resident, visitors, and the public access to the most recent survey results or plan of correction. The facility identified a census of 29 residents. An observation on 4/21/26 at 1:20 PM revealed a 3-ring binder in the lobby of the facility labeled Hemingford Care Center Survey Results. Record review of this survey results book revealed the newest survey results were from from the survey ending December 2024. The book did not include the results of the most recent survey which ended 2/2/26, or the plan of correction written for that survey. Record review also revealed there were no citations related to complaints following the previous survey included the book. [...]

Inspectors wroteLicense Reference Number 175 NAC 12-006.02 (H)Based on record review and interview, the facility failed to report an allegation of abuse or neglect to the State Agency within the required timeframe for 1 (Resident 7) of 3 sampled residents. The facility identified a census of 29. Record review of a facility document titled, Final investigation report dated [DATE], revealed that the Administrator (ADM) received an allegation of neglect on [DATE] from a family member of Resident 7. The document also revealed the family member alleged the facility had caused Resident 7's death through medical neglect. Record review of Nursing Notes dated [DATE] at 3:50 PM revealed the following:Resident 7's family member was in the facility when Resident 7 died. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 (F) (iii) Based on record review and interview, the facility failed to revise Resident 5's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) to reflect care changes made following Resident 5's grievances. This affected one of three sampled residents. The facility identified a census of 29.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10 (D) Based on record review and interviews, the facility failed to ensure a narcotic pain medication was administered as ordered for 1 (Resident 5) of 3 sampled residents. The facility census was 29. Findings Are: A record review of facility policy Administering Medications with a revision date of April 2019 revealed medications were to be administered in accordance with prescriber orders, including any required time frames. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record review and interview, the facility failed to ensure 4 of 5 sampled nurse aides (NA) completed the required 12 hours of ongoing training annually based on their date of hire. This had the potential to affect all residents. The facility identified a census of 33. Findings Are: A record review of the Facility assessment dated [DATE] revealed the in-service training for nurse aides would be sufficient to ensure the continuing competence of nurse aides, provided training must be no less than 12 hours per year. A record review of an Employee Contact List dated 10/26/2026 revealed the following:-NA-I was hired on 10/2/2024,-NA-J was hired on 12/17/2024,-NA-A was hired on 8/30/2024, and-NA-L was hired on 5/8/2022. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11 and 12-006.11(D) Based on observation, interview, and record review, the facility failed to follow recipes to conserve nutritive value, palatability, and proper temperatures of the foods served to the residents. This had the potential to effect all 33 residents served food out of the facility kitchen. Observation of food preparation on 1/27/26 from 10:00 AM to 10:45 AM with Certified Dietary Manager (CDM) revealed the CDM preparing beef tips and gravy and peas with pearled onions. The CDM retrieved the recipes as requested but at no time during preparation, referenced them. The CDM opened 2 bags of peas that were labeled as 2.5 pound bags, there were no pearled onions in these peas. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E)Based on observation, interview and record review the facility failed to use or dispose of expired foods, failed to perform hand hygiene and utilize gloves to prevent the potential for food borne illness and cross contamination. The facility also failed to test the sanitizing solution as required for dishwashing and cleaning services. This had the potential to effect all 33 residents that ate food out of the kitchen.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.19(A) Based on observation, interview, and record review; the facility failed to ensure the light fixtures throughout all halls of the facility were free of deceased bugs. This had the potential to affect all residents. The facility identified a census of 33.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F) Based on record review and interviews, the facility failed to review and revise care plans when necessary for 2 (Residents 11 and 20) of 12 sampled residents, and failed to ensure 1 (Resident 21) of 1 sampled resident representative was able to participate in the development of their care plan. The facility census was 33. Findings Are: A record review of the facility policy Care Plans, Comprehensive Person-Centered with a revision date of [DATE] revealed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. A. A record review of Resident 11's Baseline Care Plan revealed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.08(B) Based on record review and interview, the facility failed to obtain a clinical rationale from the provider to continue as needed (PRN) psychotropic medications beyond 14 days as required for 2 (Residents 6 and 13) of 5 sampled residents. The facility identified a census of 33. Findings Are: A record review of the facility's Psychotropic Medication Use policy dated July 2022 revealed that for psychotropic medications that are not antipsychotics if the prescriber or attending physician believes it is appropriate to extend the PRN (as needed) order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. A. A record review conducted on 1/29/2026 of Resident 13's January 2026 Medication Administration Record (MAR) revealed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review and interview, the facility failed to submit their investigation to the state agency for 1 (Resident 6) of 3 sampled residents within the required 5 working days for Resident 6. The facility reported a census of 33Record review of a facility-provided document titled Initial report revealed that Resident 6 was found to be wearing a brief that was overly wet and soiled at 6:00 AM on 1/2/26. The document further revealed that Nurse Aide-A (NA-A) from the shift prior was suspected of leaving the resident in the soiled brief for an extended period. The document revealed that this incident was reported to the state agency on 1/2/26. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify 1 (Resident 1) of 1 sampled resident and their representative in writing regarding the reason for their transfers to the hospital. The facility identified a census of 33. Findings Are: A record review of Resident 1's Progress Notes dated 1/2/2026 revealed the resident was transported to the emergency room at 3:11 PM and the facility confirmed at 5:14 PM the same day that the resident had been admitted to the hospital. A record review of a Bed Hold Agreement for Resident 1 confirmed the resident was placed on a bed hold on 1/2/26. A record review of Resident 1's Progress Note dated 1/19/2026 revealed the resident was sent to the emergency room at 7:10 PM. A record review of Resident 1's Progress Note dated 1/20/2026 confirmed the resident had been admitted to the hospital. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the facility failed to ensure the admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) was accurately coded in relation to the Level II Pre-admission Screening and Resident Review (PASRR, a process which requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have Serious Mental Illness or Intellectual Disability) for 1 (Resident 20) of 1 sampled resident. The facility identified a census of 33. Findings Are: A record review of Resident 20's admission Record revealed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident 11) of 12 sampled residents. The facility identified a census of 33. Findings Are: A record review of the facility policy Care Plans, Comprehensive Person-Centered with a revision date of March 2022 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide peri-cares as required to Resident 3 and failed to ensure Resident 21's lab work was obtained as ordered by the provider. The facility reported a census of 33.

Inspectors wroteBased on record review and interview, the facility failed to implement interventions to prevent and alleviate the formation and worsening of pressure injuries for Resident 23. The facility identified a census of 33. A record review of Resident 23's face sheet revealed they were admitted to the facility on [DATE] with diagnoses of traumatic brain injury, dementia, chronic obstructive pulmonary disease, and congestive heart failure. A record review of Resident 23's nursing progress notes revealed the following:On 12/11/25, Resident 23 had a peeling skin/small open area to coccyx (tailbone). The area was cleaned and a nurse aide was educated to apply barrier cream with each brief change, and staff should attempt to reduce pressure to buttocks while in bed. On 12/15/25, the same area to Resident 23's coccyx split open and measured 3.2 x 0.5 centimeters (cm). [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(J)(iii)Based on observation, record review, and interview, the facility failed to ensure one (Resident 21) of one sampled resident received adequate fluid according to dietary recommendations based on resident weight and medication orders. The facility identified a census of 33.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (Resident 6) of 5 sampled residents was seen by a primary care physician as required by the federal regulation, which is every 120 days when alternating visits with a non-physician practitioner (NPP). The facility identified a census of 33. Record Review of Resident 6's admission record reveals that resident 6 was admitted [DATE] with diagnosis of unspecified injury of head, 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. Record Review of Resident 6's Minimum Data Set (MDS) (a federally mandated assessment to help guide cares for a resident) dated 10/2/2025 revealed the following: [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.08 Based on record review and interview, the facility failed to ensure the provider reviewed and documented what, if any, actions had taken place to address the pharmacist recommendations made during their monthly medication regimen review for 2 (Residents 6 and 13) of 5 sampled residents. The facility identified a census of 33. Findings Are: A record review of the facility policy Medication Utilization and Prescribing- Clinical Protocol with a revision date of July 2016 revealed in the Treatment/Management section that the physician and staff will adjust existing medications based on their efficacy and the continued presence of relevant conditions and risks. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(H)(i) Based on an interview and record reviews, the facility failed to employ a Registered Dietitian full-time or have a certified Food Service Director. This had the potential to affect 27 residents who ate from the kitchen. The facility census identified a census of 27.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.11(E) Based on observations and interview, the facility failed to store, label, cover, and use or discard food and drink items in a manner that prevented the potential for foodborne illness. This had the potential to affect all 27 residents residing at the facility.

Inspectors wroteLicense Reference Number 175 NAC 12-006.18 Based on observations, interviews, and record reviews; the facility failed to handle contaminated linens for all residents who were residing within the facility in a way that prevented the potential for cross contamination; and the facility failed to complete hand hygiene between distributing laundry for Residents 11, 21, 130, and 131. The facility identified a census of 27.

Inspectors wroteLicensure Reference 175 NAC 12-006.04(B)(i) Based on record review and interviews, the facility failed to ensure 1 (Nurse Aide (NA)-F) of 6 sampled employees had completed initial orientation with training on abuse. This had the potential to affect all 27 residing in the facility.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(F)(i) Based on record reviews and interviews, the facility failed to develop a baseline care plan within 48 hours of admission and provide a copy to the resident or resident's representative for 5 (Residents 13, 15, 16, 20, and 22) of 8 sampled residents. The facility identified a census of 27. A record review of a facility policy Care Plans - Baseline with last revised date of March 2022 revealed under the policy statement that a baseline care plan is developed for each resident within 48 hours of admission. The policy also revealed the facility would provide a copy of the summary to the resident and/or resident representative and be documented in the medical record. A. [...]

Inspectors wroteLicensure Reference 175 NAC 12- 006.09(I) Based on record reviews and interview, the facility failed to protect 4 (Residents 9, 16, 17, and 20) from Resident 15's adverse behaviors. The facility identified a census of 27.

Inspectors wroteLicense Reference Number 175 NAC 12-006.02(H) Based on interviews and record review, the facility failed to report alleged misappropriation of resident property to a state agency within 24 hours and submit an investigation within 5 working days of the incident as required for 1(Resident 12) of 1 sampled resident. The facility identified a census of 27.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(D) Based on record reviews and an interview, the facility failed to accurately code active diagnoses, medication use, and Gradual Dose Reduction (GDR) information on the Minimum Data Sets (MDS, a standardized assessment tool that measures health status in nursing home residents) for 2 (Resident 9 and 17) of 3 sampled residents. The facility identified a census of 27.

Inspectors wroteLicensure Reference 175 NAC 12- 006.09(G)(i) Based on record reviews and interview, the facility failed to develop and provide a discharge summary that included a recapitulation (a brief review or summary) of stay for 1 (Resident 79) of 1 sampled resident. The facility identified a census of 27.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(H) Based on record reviews and interview, the facility failed to ensure two prophylactic antibiotics had stop dates and had indications for use for 1 (Resident 2) of 1 sampled resident. The facility identified a census of 27.

Inspectors wroteLicense Reference Number 175 NAC 12-006.11(D) Based on observations, record review, and interviews, the facility failed to maintain the nutritive value of pureed food. This had the potential to affect 2 residents (Residents 5 and 15). The facility identified a census of 27.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(A)(iv) Based on observation, interview, and record review, the facility failed to serve food in the texture ordered by the medical provider for two affected residents (Residents 5 and 15). The facility identified a census of 27.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(A)(iii) Based on record reviews and an interview, the facility failed to conduct nurse aide registry checks for adverse findings as required for 4 of 5 sampled employees. This had the potential to affect all 27 residing within the facility.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to submit an accurate investigation report to the state agency following an elopement for 1 (Resident 1) of 2 sampled residents. The facility census was 25. The Findings Are: A record review of a facility provided document titled New Investigation Report revealed that the Director of Nursing (DON) submitted an investigation report to the State Agency on 7/11/24 regarding the elopement of Resident 1. The report stated that the facility called the incident in to Adult Protective Services (APS) on 7/6/24 at 9:32 PM, and that the facility administrator was notified of Resident 1's elopement on 7/6/24 at 6:57 PM. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)(i)(3) Based on record review and interview, the facility failed to implement interventions to prevent elopements for 1 (Resident 1) of 2 sampled residents. The facility census was 25. The Findings Are: A record review of facility policy Wandering and Elopements with revision date of March 2019, revealed that if a resident was identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. The policy did not contain information regarding implementing new interventions after an elopement occurred and did not contain examples of interventions that could be put into place if a resident was at risk for wandering or elopements. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interviews, the facility failed to notify the resident's representative of a resident's change in condition for 1 (Resident 1) of 4 sampled residents. The facility census was 27. The Findings Are: A record review of facility policy Change in a Resident's Condition or Status with a last revised date of February 2021, revealed in #2 A 'significant change' of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions., in #4 Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D1c Based on record review, observations, and interviews, the facility failed to assist a dependent resident with toileting. This affected Resident 2. The facility identified a census of 27.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D8b Based on record reviews and interviews, the facility failed to identify a significant weight loss for 1 (Resident 1) of 4 sampled residents. The facility census was 27.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10D Based on observations, interviews, and record review, the facility failed to prepare and administer the correct dosage for 2 (Resident 8 and Resident 12) of 11 sampled residents. The medication error rate was 7.69%. The facility identified a census of 27.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D7 Based on observations, interviews, and record reviews, the facility failed to provide supervision to prevent the potential for elopement to 2 (Residents 2 & 4) of 5 sampled residents. This had the potential to affect 5 of 5 residents who resided in the facility's Memory Care Unit. The facility census was 25. The Findings Are: A record review of the facility policy Emergency Procedure-Missing Person, with a last revised date of August 2018, Policy Interpretation and Implementation #1 revealed Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety. A record review of the facility's resident roster on 1/30/24 revealed there were 5 residents residing in the Memory Support Unit (MCU). A. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04D2 Based on record review and interview, the facility failed to have a Qualified Dietary Manager. This had the potential to affect all residents who ate food served by the kitchen. The facility census was 22. A record review of the facility's dietary department staff list revealed no evidence of a Certified Dietary Manager being employed by the facility. A interview on 12/12/2023 at 10:15 AM was conducted with Registered Dietician (RD) M. During the interview RD M reported being new to the facility with plans of being at the facility monthly. RD M reported the facility did not have a Certified Dietary Manager (CDM) and was in the process of hiring one, likely from in house. RD M reported the internal candidate did not a CDM currently.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observation and record review; the facility kitchen staff failed to store food, failed to complete hand hygiene during food preparation and failed to ensure kitchen equipment was maintained in a clean manor to prevent the potential for food borne illness. This had the potential to effect all residents who ate food from the kitchen. The facility staff identified a census of 22. Based on observation, interview, and record review the facility failed to ensure equipment in the kitchen was fu. This had the potential to affect all residents who received meals from the kitchen. The facility census was 22.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18A Based on observation and interview; the facility staff failed ensure ventilation system vents were maintained in a clean functional condition for 6 rooms (rooms 103, 201, 207, 211, 305, and 307) affecting Residents 5, 6, 8, 10, 13, 14, 15, and 20 and 2) and failed to ensure bathroom vents were in working order in 2 rooms (307 and 311) affecting Residents 13 and 125. The facility staff identified a census of 22 residents at the time of the survey.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05 (8) Based on record review, observations, and interviews; the facility failed to identify a positioning wedge as a restraint for 1 (Resident 3) of 1 sampled resident. The facility identified a census of 22 residents at the time of the survey.

Inspectors wroteLicensure Reference number 175 NAC 12-006.05 (5) Based on interview and record reviews, the facility failed to provide notice to the state ombudsman of resident transfer or discharge. This failure affected 1 of 1 sampled resident (Resident 17). The facility identified a census of 22 residents at the time of the survey. A record review of Resident 17's face sheet revealed they were admitted on [DATE] with an admitting diagnosis of end stage renal disease (ESRD). Further review of Resident 17's face sheet revealed Resident 17 had a power of attorney (POA). Record review of Resident 17's Progress Note (PN) dated 7/17/2023 at 2:59 PM revealed Resident 17 was taken to the Emergency Department (ER). A record review of Resident 17's PN dated 8/4/2023 revealed Resident 17 was sent to the ER. A record review of Resident 17's PN dated 8/23/202 revealed Resident 17 was sent to the hospital. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09B1 (2) Based on record review, the facility failed to complete a significant change assessment within 14 days of determining the status change was significant for 1 (Residents 21) of 2 sampled residents. The facility census was 22.

Inspectors wroteReference Number 175 NAC 12-006.09B Based on record review and interview; the facility staff failed to identify mental illness diagnoses on a Level 1 Preadmission Screening and Resident Review (PASARR- an evaluation used to identify the presence of mental illness, intellectual disability, or related condition) for 1 resident (Resident 6) of 1 sampled resident. The facility staff identified a census of 22 residents at the time of the survey.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04C3a (5) Based on observation, record review, and interviews the facility failed to ensure 1 (Resident 14) of 2 sampled resident who received dialysis services had care plan interventions for dialysis monitoring. The facility census was 22. The Findings Are: A record review of Resident 14's admission record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of End Stage Renal Disease (ESRD). A record review of Resident 14's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning), dated 11/13/23 revealed the facility staff assessed Resident 14 with a Brief Interview of Mental Status (BIMS) of a 10. According to the MDS [NAME] a score of 8 to 12 indicates a person has moderately impaired cognition. [...]

Inspectors wroteLICENSURE REFERENCE NUMBER:175 NAC 12-006.09D2b Based observations, record reviews and interview; the facility staff failed to identify, obtain treatment and monitor the development of a pressure ulcer for 1 (Resident 20) of 1 sampled resident. The facility staff identified a census of 22.

Inspectors wrote175 NAC 12-006.09D7 Based on observations, interviews, and record review, the facility failed to utilize bath chair seatbelts during the use of the whirlpool bathing system according to the operational procedures manual for 1 (Resident 20) of 1 sampled resident. The facility census was 22.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on interview and record review, the facility staff failed to provide assessment and monitoring for 2 ( Resident 14 and 17) of 2 residents who was receiving Hemodialysis (A method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood). The facility staff identified a census of 22. The Findings Are: A. Record review of Resident 14's admission record revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of End Stage Renal Disease (ESRD). A record review of Resident 14's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 11/13/23 revealed the facility assessed Resident 14 with a Brief Interview of Mental Status (BIMS) of a 10. [...]