Hemphill Care Center

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Residents #1) reviewed for care plans. The facility failed to develop a comprehensive care plan to address the risk for developing pressure ulcers and the lack of interventions caused Resident #1 to experience a pressure ulcer to her left heel on 8/28/2025. This failure could place residents at risk of not receiving the necessary care and services.

Inspectors wroteBased on interviews and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing was provided for 1 of 4 residents reviewed for pressure injuries (Resident #1). 1. The facility did not ensure Resident #1 had orders and interventions in place related to an ankle splint to prevent pressure injuries on admission 8/07/2025.2. The facility failed to ensure Resident #1 did not develop a pressure related deep tissue injury on 8/28/2025. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 vaccine/medication storage refrigerators reviewed for labeling and storage. The facility failed to monitor and record temperatures of the refrigerator located in the medication room used for vaccine storage twice daily as required per the Centers for Disease Control (CDC) guidelines for vaccine storage when temperatures were logged for the refrigerator one time each day from September 1, 2025, until September 22, 2025. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 residents (Resident #12, #19 and #27) reviewed for infection control. 1. Facility failed to ensure CNA B and LVN A did not place Resident #12's foley catheter drainage bag (bag that drains urine from bladder) on floor during a transfer on 8/12/24. 2. Facility failed to ensure RA C washed or sanitized her hands between serving/feeding Residents #19 and #27 on 8/12/24. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 12 residents (Resident # 27) observed for care in that: RA C failed to sit while feeding Resident #27 in the dining room on 8/12/2024. This failure could place residents at risk of not being treated with dignity and respect.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 4 residents reviewed for accident hazards. (Resident #27) The facility failed to develop and implement a policy and procedure to properly handle the care of Hoyer lift slings including interventions to inspect the Hoyer sling for signs of damage before each use and not removing damaged slings from service for Resident #27. This deficient practice could place residents at risk of falls and injuries if damaged lift sling broke during mechanical lift transfers.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 2 of 29 residents reviewed for call lights. (Resident #11 and Resident #21) The facility failed to ensure Resident #11 and Resident #21's emergency call light in the bathroom had a cord enabling it to be reachable from the floor. This failure could place residents at risk of not receiving care and services to maintain highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for for 2 of 3 days reviewed (8/12/2024 and 8/13/2024) nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 8/12/2024 and 8/13/2024. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the facility had an Administrator licensed by the state that was responsible for management of the facility for 1 of 1 facility's reviewed for governing body. The facility failed to ensure the Assistant Administrator, who was acting as the facility Administrator, had an active Texas Administrator license. This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 8 residents reviewed for resident rights. (Resident #1). The facility failed to ensure CNA A respected Resident #1's rights and dignity during her shower on 5/29/24. The noncompliance was identified as PNC. The Immediate Jeopardy began on 5/29/24 and ended on 5/31/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of becoming distressed and feeling disrespected.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents the right to be free from abuse and/or neglect for 1 of 8 residents reviewed for abuse and/or neglect. (Resident #1) The facility failed to prevent CNA A from verbally, physically and mentally abusing Resident #1 while giving Resident #1 a shower on 5/29/24. The noncompliance was identified as PNC. The Immediate Jeopardy began on 5/29/24 and ended on 5/31/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of emotional harm, abuse/neglect, humiliation, intimidation, fear, shame, agitation, degradation, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents and hazards for 1 of 7 residents (Residents #1) reviewed for supervision. Resident #1 accessed the staff breakroom, obtained staff car keys, accessed staff's car, and drove off the premises on [DATE]. This failure places residents at risks for inadequate monitoring and supervision.

Inspectors wroteBased on observation, interview and record review the facility failed to immediately inform the resident's responsible party when there was an accident involving the resident which resulted in injury or had the potential for requiring physician intervention for 2 of 8 residents (Resident #1, and Resident #2) reviewed for notification of change of condition. The facility failed to notify Resident #1's responsible party and physician when Resident #1 sustained a witnessed fall on 3/3/24 in her room when she was found sitting on the floor. The facility failed notify Resident #2's responsible party and physician when Resident #2 sustained a bruise to her right eye on 3/31/24 after hitting her face on the wall while being turned for incontinent care. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from abuse for 4 of 10 residents (Resident #12, Resident #184, Resident #185, and Resident #186) reviewed for Resident Abuse. 1. The facility failed to protect Resident #185 from abuse by Resident #2. On 11/22/2022 Resident #185 wandered by Resident #2's door on the secured unit, and Resident #2 grabbed Resident #185's arm and struck her in the upper chest. 2. The facility failed to protect Resident #185 from abuse by Resident #2. On 12/05/2022 Resident #185 wandered into Resident #2's room on the secured unit, and Resident #2 punched Resident #185 in the face causing an abrasion to her left check . 3. The facility failed to protect Resident #186 from abuse by Resident #2. On 01/15/2023 Resident #2 grabbed and yanked Resident #186's arm backwards. 4. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibit abuse/neglect for 4 of 10 residents (Resident #12, Resident #184, Resident #185, and Resident #186) ) reviewed for incidents. The facility failed to implement their abuse policy and program to prevent abuse when Resident #2 abused Resident #12, Resident #184, Resident #185, and Resident #186. An IJ (immediate jeopardy) was identified on 07/11/2023 at 4:13 PM. The IJ template was provided to the facility on [DATE] at 4:13 PM. While the IJ was removed on 07/13/2023 at 3:35 PM, the facility remained out of compliance at a severity level of actual harm that is not immediate with a scope of pattern due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to thoroughly investigate and take measures to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in process, and failed to ensure corrective action was taken for 4 of 10 residents (Resident #12, Resident #184, Resident #185, and Resident #186) reviewed for abuse. 1. The facility failed to investigate allegations of abuse and ensure corrective actions were in place when Resident #2 hit Resident #185 in the chest on 11/22/2022. 2. The facility failed to investigate allegations of abuse and ensure corrective actions were in place when Resident #2 hit Resident #185 in the face causing an abrasion to her cheek on 12/05/2022. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for 1 (Resident #186) of 1 resident reviewed for notification of change. The facility failed to immediately consult with the resident's physician when Resident #186 had a significant decline in condition as evidenced by pupil changes and behavior changes, which resulted in his death. An Immediate Jeopardy (IJ) situation was identified on 07/12/23 at 11:15 am. The IJ template was provided to the facility on [DATE] at 11:30 am. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #186), reviewed for quality of care. The facility failed to promptly identify and intervene for an acute change in Resident #186 following a fall resulting in him being transported to the hospital with bilateral subdural hematomas, which resulted in his death. An Immediate Jeopardy (IJ) situation was identified on 07/12/23 at 11:15 am. The IJ template was provided to the facility on [DATE] at 11:30 am. [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 2 of 3 months reviewed. (February 2023 and March 2023) The facility did not have RN coverage for 1 day in February 2023. The facility did not have RN coverage for 3 days in March 2023. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that: The facility failed to ensure an opened items in the reach in refrigerators were labeled and dated correctly. The facility failed to ensure all food items were discarded by the expiration date. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 refrigerator in the kitchen reviewed for essential equipment. The facility did not ensure the refrigerator was in safe operating condition. The refrigerator had built up condensation in the top of the refrigerator that was melting and leaking water in food and storage containers within the refrigerator. This failure could place the residents at risk of food borne illnesses and not having safe operating equipment.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 4 of 10 residents (Resident #12, Resident #184, Resident #185, and Resident #186) reviewed for abuse and neglect. 1. On 11/22/2022 Resident #185 wandered by Resident #2's door on the secured unit, and Resident #2 grabbed Resident #185's arm and struck her in the upper chest. The incident was not reported to the state agency as required. 2. On 12/05/2022 Resident #185 wandered into Resident #2's room on the secured unit, and Resident #2 punched Resident #185 in the face causing an abrasion to her left check. The incident was not reported to the state agency as required. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing and administering of medications for 1 of 1 medication storage room reviewed for pharmacy services. The facility failed to properly date tuberculin PPD (purified protein derivative) Mantoux testing solution in the medication storage refrigerator with an open date. The facility failed to remove 3 vials of Flucelvax from the medication storage room refrigerator that had expired on 06/30/2023. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident # 1 and Resident #17) reviewed for infection control. LVN J failed to clean the scissors used to cut wound care dressings for Resident #1 and she stored the scissors in her pocket. CNA I failed to change her gloves when going from dirty to clean while providing incontinent care for Resident #17. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 3 resident personal refrigerators reviewed for food safety (Resident #14). The facility failed to ensure the refrigerator for Resident #14 did not contain expired milk. This failure could place resident at risk for food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2023 for the second quarter January 1, 2023, to March 31, 2022) The facility failed to submit accurate RN hours for: 02/11 (SA); 02/12 (SU); 02/13 (MO) 03/16 (TH); 03/17 (FR); 03/18 (SA); 03/20 (MO); 03/21 (TU); 03/22 (WE); 03/23 (TH); 03/24 (FR); 03/25; (SA); 03/26 (SU); 03/27 (MO); 03/28 (TU); 03/29 (WE); 03/30 (TH); 03/31 (FR) These failures could place residents at risk for personal needs not being identified and met.