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Complaint Investigation

Hemingford Care Center

April 27, 2026 · Hemingford, NE · 605 Donald Avenue
Citations 4
CMS Rating 1/5
Beds 39
Provider ID 285306
Healthcare Facility
Hemingford Care Center
Hemingford, NE  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Hemingford Care Center in Hemingford, NE — inspection on April 27, 2026.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0577
Resident Rights Deficiencies

agencies.

the facility failed to give residents, family members, legal representatives of the resident, visitors,

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. An Interview on 4/21/26 at 1:29 PM with the administrator confirmed the required documents were not included in the survey book.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

285306 04/27/2026

Hemingford Care Center 605 Donald Avenue Hemingford, NE 69348

authorities.

Reference Number 175 NAC 12-006.02 (H)Based on record review and interview, the facility failed to

(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.The nurse, Licensed Practical Nurse-C (LPN-C), assessed Resident 7 for signs of life and no heartbeat was detected at 2:39 PM.A provider had ordered a hospice consult for Resident 7, however the consult had not occurred yet.The administrator (ADM) was updated at 3:03 PM on [DATE].The family member used a raised voice throughout the facility, saying the facility had murdered Resident 7, and other residents became distressed.

Record review of Nursing Notes dated [DATE] at 4:50 PM revealed the ADM spoke with local law enforcement regarding the family member's allegations and the ADM provided the sheriff with the requested information.A record review of Resident 7's advanced directive signed by the resident on [DATE] revealed the resident desired cardiopulmonary resuscitation (CPR) if their heart stopped beating.A review of Resident 7's physician orders and care plan in Point Click Care revealed CPR was still indicated at the time of Resident 7's death.The facility notified the State Agency of the allegation of neglect on [DATE] at 1:51 PM.An interview on [DATE] at 12:25 PM with the ADM confirmed they did not notify the state agency within 2 hours as required.

285306 04/27/2026

Hemingford Care Center 605 Donald Avenue Hemingford, NE 69348

concern for finances and medications. An interview with Regional Nurse Consultant (RNC) on 4/21/26

pairs. An interview with Director of Nursing (DON) on 4/21/2026 at 3:30 PM confirmed that the only

with Resident 5 on 4/27/2026 at 10:47 AM confirmed that NA-A still goes into Resident 5's room.

285306 04/27/2026

Hemingford Care Center 605 Donald Avenue Hemingford, NE 69348

indicated on the March and April 2026 MARs, including 10 consecutive occasions on 4/5/26 and

stated I don't know what they did before me as far as reordering the meds. We are doing education

yesterday. An interview on 4/21/2026 at 4:49 PM with the Administrator confirmed Resident 5 had not received their Percocet medication as ordered during the months of March and April 2026.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Hemingford, NE, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Hemingford Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.