Latest reports, citations, and penalties from CMS data
The facility's own care plan, initiated on September 17, 2024, identified the resident's "behavior wandering into other resident's room" as a focus area....
The failure occurred when both the ignition control module and gas valve malfunctioned, requiring replacement parts that were not immediately available....
The incident occurred despite a hand washing sink being available at the nursing station....
The aide later confirmed she understood the resident required Enhanced Barrier Precautions but failed to follow the protocol....
The error occurred consistently from March through June 2024, with documentation showing incorrect application on multiple dates....
When blood sugar remains elevated for extended periods, patients face risks including severe dehydration, electrolyte imbalances, and organ damage....
During the inspection, surveyors observed flies directly landing on residents....
Despite these documented risk factors, facility staff failed to maintain adequate supervision....
When these systems fail, residents face potentially life-threatening delays in receiving help for medical emergencies, falls, or other urgent situations....
The resident then "leaned forward and slowly slid off the foot plate of the sit-to-stand," according to Staff C's account to investigators....
The violations occurred despite facility policies requiring physician orders and proper assessments before implementing any restraint measures....
The resident had a **Stage 4 pressure ulcer** on the sacrum - the most severe type of pressure wound that exposes fat tissue beneath the skin....
## Controlled Medication Storage Failures The most significant violation involved the improper storage of Tramadol, a controlled pain medication....
Hypernatremia occurs when sodium levels in the blood become dangerously elevated, typically due to inadequate fluid intake or excessive fluid loss....
The bathroom showed signs of significant deterioration and potential contamination that had been left unaddressed by facility maintenance staff....
Blood pressure readings help monitor cardiovascular health and medication effectiveness....
These violations posed immediate danger to vulnerable residents who depend on precise blood sugar control....
This represents a breakdown in the facility's internal oversight systems designed to identify and correct problems before they impact resident care....
## Pattern of Licensing Oversights The inspection documented systematic failures in the facility's employee verification system....
Resident 18, who has diagnoses including schizophrenia and bipolar disorder, made inappropriate comments to her roommate, Resident 103....