Caleb Hitchcock Health Center

In the surveyor’s words

From the most serious findings on record at Caleb Hitchcock Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Nov 25, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF684Nov 25, 2025

  Based 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. […]

• Actual harm, isolatedF600Nov 17, 2025

  Based 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. The findings include:Resident #1's diagnoses included dementia. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of one out of fifteen, indicative of severe cognitive impairment, was incontinent of bowel and bladder, was dependent on staff for personal hygiene, and required maximal assistance with bed mobility. […]

• No harm, potential for more than minimal, widespreadF882Nov 25, 2025

  Based 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. The findings include: Interview with the Director of Nursing Services (DNS) on 11/19/25 at 2:00 PM identified that she was designated as the Infection Preventionist (IP) in October 2025 until a new IP was hired to the position.Interview with Registered Nurse (RN) #8 on 11/24/25 at 10:30 AM identified she was a full time RN-Designee at the Assisted Living Services Agency (another entity of the Long Term Care Facility) and was not actively a facility employee. […]

• No harm, potential for more than minimal, widespreadF812Jan 24, 2024

  Based 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. The findings include: Tour of the Dietary department on 1/18/24 at 10:32 AM and 1/23/24 at 12:16 PM with the Director of Dietary identified the following: 1a. A 1 gallon container that was 1/4 full of fresh, peeled garlic was observed to be located inside the reach in cooler and was noted to be opened but not labeled with the date of opening, contained a green substance inside the container and lacked an expiration date. b. […]