Latest reports, citations, and penalties from CMS data
The incident occurred on September 9, 2025, at Colonial Gardens Nursing Home when Resident 5 told Licensed Vocational Nurse 11 that someone had hit him....
Daily weights are essential for heart failure patients because sudden weight gain signals dangerous fluid buildup that can lead to hospitalization or death....
The resident had completed a POLST form electing "do not attempt resuscitation" status....
On November 12, inspectors found her nebulizer mask and tubing sitting uncovered on her nightstand instead of stored in a protective bag....
No staff members were present in the hallway....
Without his call light within reach, he had no reliable way to alert staff when he needed help....
The September 18 incident occurred while EMTs waited outside the room to transport the resident for a weekly medical procedure....
Resident #3 had been receiving weekly treatment at a local wound care clinic under Medical Director #1....
The verbal confrontation involved a resident who sings in the hallways as part of her normal behavior....
The falsified medication record at Civita Care Center involved Alprazolam, a controlled substance prescribed for a resident's anxiety disorder....
Water temperatures measured as low as 88 degrees in some bathrooms, while one room had no hot water at all....
One minute later, the nurse passed by the inspector and went behind the nursing station, stating she was finished distributing medications....
The resident's power of attorney and daughter was not contacted until noon, despite facility policy requiring immediate notification of emergency incidents....
Resident #7, who has quadriplegia and bladder dysfunction, was supposed to receive Midodrine only when his systolic blood pressure dropped below 120....
Resident 2 returned to Ashland Post Acute on January 27 following treatment for an infection....
The pest infestation extended beyond the dining room....
What prompted that September admission at Hadley Pointe Nursing Rehab & Care was a scene of neglect that had been building for months....
Staff B, a licensed practical nurse, overheard the exchange on November 12 at 7:25 PM through Resident #3's roommate's baby monitor....
The nurse wrote that the resident's blood pressure was 156/80, her pulse 83, and her oxygen saturation 95 percent....
The residents, all cognitively intact, said they repeatedly asked staff to replace the soap but were ignored....