Latest reports, citations, and penalties from CMS data
The nurse inspectors identified as LVN B told investigators she had been trained on skin assessments when she was hired in September 2023....
That is a gap of two hours and forty-six minutes, well outside the window that both the facility's nursing staff and its director described as acceptable....
The deficiency was one of eight cited during the inspection....
That plan, required to be prepared, reviewed, and revised by a team of health professionals, is not a formality....
The inspection, completed September 16, 2025, was a complaint investigation, not a routine survey....
The facility's medical director learned about the incident and did not hide his reaction....
The surveyor arrived in the room of a resident identified in inspection records as R6 at 8:30 in the morning and did not leave until 9:28....
The facility is disputing the citation....
The inspection, completed September 19, 2025, was triggered by a complaint....
The inspection, conducted on September 15, 2025, was triggered by a complaint....
Inspectors classified it as a pattern, meaning this wasn't a single lapse on a single shift....
Resident council minutes from July 7, 2025, documented the problem by name, under a section labeled "Nursing," with a note that ice water was not being passed....
That is the core of what federal health inspectors found when they arrived at the facility on a complaint inspection last fall....
The care plan requirement exists because residents in long-term care are, by definition, people with complex needs....
Inspectors classified the violation as isolated, with no documented actual harm, but with potential for more than minimal harm....
The inspection, conducted September 15, 2025, was triggered by a complaint....
She soiled herself shortly after....
The citation, issued September 17, found that the facility failed to develop and implement care plans that fully addressed residents' needs....
Federal health inspectors visited the facility on September 17, 2025, responding to a complaint....
The incident happened on August 28, 2025....