Latest reports, citations, and penalties from CMS data
## 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....
Inspectors documented three separate medication errors that demonstrated systemic failures in basic safety protocols....
The resident required seven different medications to be crushed and administered through the gastrostomy tube....
These protocols extend beyond standard precautions and require specific protective equipment during high-risk procedures....
The resident, who had chronic obstructive pulmonary disease and chronic respiratory failure, had not had a bowel movement for two to three days....
"The wedges should be placed under the bed sheet and not under the mattress," acknowledged an LPN supervisor during the inspection....
Multiple residents reported waiting between one to two hours for help with toileting, personal hygiene, and other essential care....
The incident came to light when a passerby noticed someone walking up a hill who appeared to be a facility resident and alerted staff at 4:15 PM....
**Resident #34** was scheduled to receive eight different medications at 8:00 AM and 9:00 AM but only received three....
**The resident provided a written statement saying "I do not want her again....
The resident's care plan specifically mandated that staff "inspect his skin before and after applying the AFO" and conduct weekly skin assessments....
## Three Falls in Three Days The incident sequence began March 15 when the resident rushed to a shared bathroom without his walker....
The incident occurred on February 11, 2025, at 1:04 p.m....
The immediate jeopardy designation indicates conditions that pose an immediate threat to resident health and safety....
During the 4:55 AM medication administration, the nurse wore only disposable gloves but failed to don the required protective gown....
This reading, documented at 4:16 PM by medication aide MA C, represents a hypertensive crisis level that requires immediate medical attention....
The incident occurred on March 4, 2025, when the resident exited the facility at 5:09 AM through the front door....
Internal facility audits confirmed these missed treatments, yet administrators remained unaware of the widespread service gaps....
A mental health worker attempted to de-escalate the situation, but the resident pushed the staff member....