Axiom Gardens: Resident Missed Dinner, Got PB&J - IL
The resident told inspectors he normally eats in his room and wasn't sure why staff didn't serve him supper that night....
Latest reports, citations, and penalties from CMS data
The resident told inspectors he normally eats in his room and wasn't sure why staff didn't serve him supper that night....
Bethany Life's own resident rights acknowledgement outlines protections that appeared relevant to this case....
The resident entered hospice services immediately upon admission on September 3....
Fairway Oaks issued a transfer notice on July 21, 2025, with an effective date of August 19, 2025....
The resident, identified only as Resident 1, left the facility on October 7, 2025, for what should have been a routine temporary leave....
Resident #165 was discharged on April 11 to another skilled nursing facility....
The facility's own policy requires comprehensive skin assessments for all residents....
The facility's director of nursing learned on October 29 that a staff nurse was unable to reorder medications for two residents....
The October incident at WeCare at Mt Lebanon Rehabilitation and Nursing Center exposed a facility-wide breakdown in basic safety protocols....
"I should've gotten up 2 hours ago," she said from her bed at Evervella of Swansea....
Her condition was complicated by depression and medication side effects that made accidents more likely....
Federal inspectors documented the November 16 incident at EverVella of White Hall during a complaint investigation....
"Resident attempted to feed a horse during activities, but was accidently bit on the left 4th digit," nursing notes from the day stated....
The violations centered on the facility's failure to follow its own policies requiring annual flu shots and pneumococcal vaccinations for all residents....
Resident #2 was supposed to receive 14 different medications at 9 AM that morning....
The facility's reportable event form documented the allegation at 4:40 PM that day....
When inspectors arrived at Tarzana Health and Rehabilitation Center on November 21, they found the lobby's Temperature Control Box 2 switched off at 9:45 a.m....
Licensed Vocational Nurse 3 administered hydralazine to Resident 4 on November 8, 2025, at 9 p.m., despite the resident's blood pressure measuring 100/67 mmHg....
The incident happened on November 9, 2025....
Without these supplies within arm's reach, any bleeding emergency could turn deadly while staff scrambled to locate equipment....