Latest reports, citations, and penalties from CMS data
These individuals may wander, fall, become agitated, or engage in behaviors that could harm themselves or others....
The resident's medical assessment showed a BIMS (Brief Interview for Mental Status) score of 4, indicating severely impaired cognition....
June showed similar patterns with AM temperatures recorded just 3 out of 30 days and PM temperatures documented only 2 out of 30 days....
This created dangerous delays during critical moments when every second matters for patient survival....
The Medical Director documented this incident, which created substantial fire hazards throughout the facility....
This represents a fundamental breakdown in the nursing home's internal oversight system designed to identify and resolve patient care problems....
Federal regulations require facilities to immediately notify physicians and family members when residents experience significant changes in condition....
The MDS assessment system serves as the foundation for determining appropriate care levels and Medicare reimbursement rates for nursing home residents....
The incident occurred in February 2025 when the CNA disregarded established protocols....
The violations occurred despite facility policies requiring all medications to be stored in locked compartments inaccessible to residents and visitors....
The resident was observed moaning, shouting, and grimacing during routine care activities like repositioning and personal care....
The situation became so concerning that it was **reported to the sheriff's office** for investigation....
According to inspection records, the facility had only one full-time cook and one part-time cook for day shifts, with no dedicated cook for evening hours....
The pharmacist's note specifically stated: "This resident continues on Trazadone 75mg qhs from 6/18/2023....
The resident, identified as Resident #5, had been admitted with multiple conditions including a spinal compression fracture, hypertension, and gout....
Federal inspectors determined that staff failed to follow established protocols during a transfer that resulted in resident injury....
This represents a fundamental breakdown in the facility's internal oversight mechanisms designed to identify, analyze, and resolve care quality issues....
Between monitoring checks, the resident successfully cut her right wrist with a microblade razor she had ordered online....
When investigators interviewed Resident 1, they found her call light cord wrapped around the bed frame and completely out of reach....
This delegation of responsibility created a dangerous gap in medical communication....