Hemingford Care Center: Pain Medication Failures - NE
The medication was Percocet, an opioid prescribed for pain. It was not given as ordered across multiple occasions documented on the facility's March and April 2026 medication administration records. On April 5 and 6 alone, the resident missed ten doses in a row.
The problems did not stop there. On April 26, the resident missed three more doses. On April 27, the day inspectors were on site conducting interviews, they missed four more.
The interim Director of Nursing, interviewed that afternoon at 2:28 PM, confirmed the missed doses and offered an explanation that raised its own questions. "I don't know what they did before me as far as reordering the meds," she told inspectors. She said the facility was now doing education and had started checking on Thursdays to make sure there was enough medication to last through the weekend. She added that the order had been placed the day before.
That means Percocet was ordered on April 26, the same day the resident missed three doses of it.
The facility's administrator had been interviewed six days earlier, on April 21 at 4:49 PM. She confirmed the same thing: Resident 5 had not received their Percocet as ordered during March and April 2026.
Two senior staff members, on two separate occasions, confirmed the pattern. Neither interview, as recorded in the inspection report, included an explanation for how the gaps had been allowed to accumulate across two full months.
Percocet is a combination of oxycodone and acetaminophen, prescribed when pain requires around-the-clock management. When doses are missed, the gap is not abstract. Pain that the medication was ordered to control goes unmanaged. For a nursing home resident, who cannot drive to a pharmacy or advocate through channels available to people outside institutional care, a missed dose means waiting, and asking, and waiting again.
The inspection classified the harm level as minimal harm or potential for actual harm, and noted that few residents were affected. The complaint was filed against Hemingford Care Center, a long-term care facility in the small western Nebraska town of Hemingford.
What the records show is a facility that allowed a controlled pain medication to run out, not once, but across a span of weeks, on multiple separate occasions, without a system in place to catch it before the resident went without. The Thursday check and the education the interim DON described were responses to what inspectors found, not practices that had prevented the problem.
The administrator knew by April 21 that the resident had gone without Percocet throughout March and April. The medication still was not on hand five days later, when the resident missed three more doses on April 26.
Hemingford Care Center had no comment included in the inspection record.
The resident identified in the report only as Resident 5 missed their pain medication on at least two days in March, continued missing it into April, went ten consecutive times without it on a single weekend, and was still not receiving it as ordered on the morning inspectors sat down to ask why.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hemingford Care Center from 2026-04-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Hemingford Care Center in Hemingford, NE was cited for violations during a health inspection on April 27, 2026.
The medication was Percocet, an opioid prescribed for pain.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.