Latest reports, citations, and penalties from CMS data
LVN A admitted Resident #101 on September 12, 2025, but never initiated the required baseline care plan....
The resident had been readmitted to the facility in July with a stage IV pressure wound and bone infection....
Nursing assistants #4 and #5 were working the 3:00 PM to 11:00 PM shift when they entered the resident's room to help transfer her to bed around 10:30 PM....
The most recent assessment should have been conducted in September 2025, according to the Director of Nursing....
The immediate jeopardy citation focused on elopement prevention failures that put residents at risk of leaving the facility unsupervised....
CNA B said the resident had fallen....
The most serious omission involved Resident #4, whose quarterly assessment completely ignored three falls that occurred over a three-month period....
The undocumented medications included insulin and anti-anxiety drugs given to Resident #1 on October 27 and 28 at McAllen Nursing Center....
Federal inspectors found the communication breakdown violated requirements for prompt reporting of diagnostic results....
The medication error occurred November 13 at 5:20 p.m....
The family had specifically requested the rings remain on her hands during her final days because removing them would have devastated her....
The November incident involved a patient admitted in September with a stroke diagnosis and moderate cognitive impairment....
The facility's own policy required a care plan within one business day....
The incident at Rivergate Health Care Center involved a resident with severe cognitive impairment who scored 0 out of 15 on a mental status exam....
The resident's family had expressed concerns about her increasing confusion before September 15, when staff finally ordered a urine test....
But a review of his electronic medical records from August 7 through September 22 turned up no documentation of the restraint....
Narcotic control sheets showed staff signed out the powerful painkiller 22 times from October 19 through October 28....
The facility's licensed social worker didn't contact the state agency until later that evening....
The nurse administered all three at 12:06 a.m....
The technician, identified as CMT B, confused two newly admitted residents who shared the same first name and lived across the hall from each other....