Latest reports, citations, and penalties from CMS data
This cognitive limitation makes residents particularly vulnerable to psychological harm from verbal abuse and intimidation tactics....
This represents a breakdown in the continuous quality improvement cycle that nursing homes must maintain to ensure resident safety and care quality....
The facility's medication error rate reached **16 percent** - more than three times the maximum allowable rate of 5 percent established by federal regulations....
## Night Shift Staff Behavior Raises Concerns During the investigation, three different residents independently reported problems with nighttime caregivers....
The dietary manager confirmed during a later interview that the facility had been experiencing ongoing issues with fly infestations in the kitchen....
The most concerning case involved a resident with a left shoulder fracture who experienced an eight-month delay in follow-up orthopedic care....
**Blood pressure medication administered when contraindicated** presented a particularly serious risk....
Federal regulations require nursing facilities to develop these preliminary care plans within 48 hours of admission....
When patients become anxious, they may fight against the ventilator, leading to inadequate oxygenation and cardiac stress....
However, the facility failed to arrange timely specialist consultation....
Despite having a care plan that specifically addressed pressure ulcer prevention, staff did not follow the established protocols....
The resident was immediately transported to the local hospital emergency department, where physicians discovered two significant lacerations....
The inspection focused on **Resident 3**, who was prescribed levofloxacin (Levaquin) 500mg daily for a urinary tract infection through a feeding tube....
When the resident asked the nurse to stop because it was causing pain, the nurse reportedly continued the procedure....
They required substantial assistance with daily activities and mobility due to their above-knee amputation....
The incident occurred on June 5, 2024, when physical therapy staff applied an e-stim device to a resident's right leg and left the room during treatment....
Despite these visible symptoms and an active prescription for Sinemet, the facility's April 2025 assessment omitted the neurological diagnosis entirely....
The violations centered around the facility's failure to recognize, investigate, and report abuse incidents as required by federal regulations....
This approach, known as person-centered care, aims to treat the root cause of behavioral symptoms rather than simply medicating them....
Despite this clear directive, nursing staff did not follow the facility's own emergency protocols....