Latest reports, citations, and penalties from CMS data
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....
The physician ordered a Depakote serum level test to be collected on February 25, 2025, following the pharmacist's recommendation....
For patients with chronic lung conditions, dry oxygen can cause airway irritation, increased mucus production, and breathing difficulties....
The facility's Infection Preventionist confirmed during an interview that the resident had MRSA in his leg wounds and was receiving antibiotic treatment....
The resident, who had dementia and exhibited physical behaviors, rejection of care, and wandering, began hospice services on January 17, 2025....
Medical records showed the resident's weight began declining sharply in April, with an 8-pound loss in just one month between April and May....
The April 5 incident was particularly serious - an unwitnessed fall that resulted in a head laceration and emergency room evaluation....
The violations center on the facility's inability to follow through on promises made after a previous citation in June 2024....
When the staff member called out to Resident 2 and asked what they were doing, the perpetrator stopped and walked back to their own bed....
The Nurse Manager did follow proper hand hygiene protocols between steps but failed to don the required gown before beginning the procedure....
Similarly, Resident #42 displayed symptoms starting April 26, progressing to a "congested cough and hoarse voice" by April 29....
This fundamental breach of medication management protocols creates significant health risks....
The violations affected up to 43 residents who regularly ate in the facility's dining areas....
The kitchen failed to maintain basic food labeling and dating protocols, with multiple items stored without proper identification or expiration dates....
According to the inspection findings, the resident's speech therapist had evaluated her multiple times between admission and discharge from therapy services....
The fall resulted in immediate transport to the emergency room for treatment of injuries sustained in the accident....
## Two-Hour Search Ends with Resident Found in Dangerous Location The facility initiated a "Dr....