Latest reports, citations, and penalties from CMS data
The patient required Sevelamer Carbonate 800 milligrams three times daily before meals to manage hypocalcemia related to kidney failure....
This suggests the current pain management approach was inadequate....
The investigation centered on Resident 47, who has dysphagia following a stroke, dementia, and a history of aspiration pneumonia....
This represents a serious breakdown in the nursing home's internal oversight systems that are mandated to protect residents....
These systems are required by federal law to continuously monitor care quality and identify potential problems before they harm residents....
More concerning, the CNA stated they were unaware that the facility even had an Abuse Coordinator position....
The inspection conducted on March 7, 2025, revealed widespread temperature control failures that put elderly residents at significant risk of severe burns....
Missing even a single dose of blood thinners can significantly increase the risk of stroke or pulmonary embolism....
## Documented Bathing Deficiencies The May 2025 inspection revealed significant gaps in resident bathing documentation at the 5976 US-65 North facility....
The resident told Licensed Practical Nurse Staff A that they felt their roommate was "trying to kill" them and had put a blanket over their face....
Inspectors observed 26 medication administration opportunities and documented two critical errors involving life-saving medications....
The incident had immediate physical consequences....
The violations affected at least four residents requiring daily injections for diabetes management and blood clot prevention....
## Unlicensed Oxygen Therapy Administration The most serious violations involved four residents receiving oxygen therapy without proper medical authorization....
"He was unable to reach the call light from his position on the shower chair," according to the federal inspection report....
This violation created unnecessary risk of head trauma during seizure activity....
## Food Safety and Temperature Violations The most widespread issue involved food service failures affecting residents across the facility....
The resident's medical records documented diagnoses including depression and a history of sexual behaviors related to psychiatric illness....
The resident's initial smoking safety evaluation from 2022 incorrectly indicated he did not use tobacco, leading to the absence of necessary safety protocols....
This represents a critical breakdown in the facility's internal oversight systems designed to ensure quality care for residents....