Latest reports, citations, and penalties from CMS data
The specific nature of the medication violations was documented as part of complaint investigation AL00050173....
The facility obtained the X-ray on July 11, 2024, and results showed "calcaneus erosion consistent with osteomyelitis" - a serious bone infection of the heel....
The most severe case involved a resident who missed 21 doses of gabapentin over six days without any physician notification....
The violations occurred despite facility policies requiring staff to report suspected theft or misappropriation to the State Survey Agency....
The male resident involved in the incident had been diagnosed with metabolic encephalopathy, cognitive communication deficits, and blood cancer....
The breakdown extended to nursing assistants who provide direct resident care....
On January 22, residents were scheduled to receive baked chicken breast, seasoned green beans, mashed potatoes with gravy, wheat roll, and fresh fruit....
Bank statements showed the resident's account balance plummeted from $9,539.98 in July 2024 to just $496.46 by October 2024....
One resident with spinal stenosis and muscle weakness reported waiting **up to 2 hours** during nighttime shifts for staff to respond to calls for help....
## Food Contamination Incident Raises Infection Control Concerns The most alarming violation occurred during breakfast service in the secure dementia unit....
The facility's director of nursing approached and questioned why the door remained open during such intimate care....
The affected resident presented with multiple serious medical conditions including chronic heart failure, kidney disease, and severe cognitive impairment....
On November 28-29, 2024, a nursing assistant discovered the resident "bright red and shaking with fresh blood on his right forearm" from a skin tear....
The facility failed to establish required time limits for lorazepam, an anxiety medication prescribed on an as-needed basis....
Despite this clear requirement, the certified nursing assistant was performing bed linen changes alone....
When inspectors contacted the listed physician, **the doctor stated the facility was not one where he sees residents**....
During the inspection, surveyors observed a nurse aide exiting a COVID patient's room wearing only a blue surgical mask after performing close-contact care....
This violation was classified as causing "minimal harm or potential for actual harm" but affected many residents throughout the facility....
The May 16, 2025 inspection revealed that on May 2, staff lost track of a 53-year-old resident with documented cognitive impairment and wandering behaviors....
## **Facility's Inadequate Response Exposed** Federal inspection records reveal significant gaps in how administrators handled the abuse allegation....