Latest reports, citations, and penalties from CMS data
The facility's own assessment indicated a need for 12-18 nursing assistants per day to properly care for an average census of 109 residents....
## Serious Medication Security Violations The most concerning findings involved **medication cart security breaches** throughout the facility....
The bathing schedule showed concerning gaps, including the entire month of August 2024 and January 2025 when no showers were documented at all....
Federal inspectors observed nursing staff using the same glucose meter on multiple diabetic residents without proper disinfection between uses....
Multiple residents reported waiting **30 minutes to over an hour** for their call lights to be answered, creating serious health and safety risks....
The violations affected staff across multiple departments, including certified nursing aides, housekeeping, and maintenance personnel....
On October 3, 2024, nursing staff discovered maggots in the resident's right heel wound during a routine dressing change....
Three of these individuals had been employed in nursing roles since 2021, while two others had worked without proper licensing since 2023....
Despite this nurse providing a written statement about what she observed, facility administration conducted no thorough investigation....
The inspection revealed systemic breakdowns in basic safety protocols affecting multiple areas of resident care....
The violations involved improper handling of medical equipment and inadequate use of protective equipment when caring for vulnerable residents....
The most recent documented assault had occurred just weeks before the transfer....
Water at 127 degrees Fahrenheit can cause first-degree burns in just one minute of exposure....
Long, untreated toenails in elderly residents create significant health risks beyond discomfort....
By May 2025, the 58-year-old resident reported she could no longer see faces, read books, or even see her food during meals....
On February 4, 2025, the facility's administrator received a report that CNA #1 had been physically rough with a resident during a transfer attempt....
However, **no evidence existed that the serum level was ever drawn**, and neither the physician nor nurse practitioner followed up on the missing results....
The meal remained at room temperature for nearly three hours....
The facility demonstrated multiple failures in outbreak management....
The wound was first documented on July 3, 2024, but **staff never measured the wound** and failed to track its progression over the following month....