Latest reports, citations, and penalties from CMS data
The resident was treated with antibiotics on January 2-9, January 22-27, February 8-19, February 13-21, April 29-May 6, and May 21-28....
These failures affected several cognitively impaired residents who depended on staff protection and proper administrative oversight....
Despite this significant deficit, the facility's initial Elopement Risk Tool assessment rated R1 at zero out of nine points for elopement risk....
Despite this documented incapacity, the facility had no valid informed consent on file for the haloperidol that had been prescribed since March 2024....
Enhanced barrier precautions represent a critical defense against healthcare-associated infections, particularly for residents with indwelling medical devices....
The oxygen therapy compliance failure represents a critical breakdown in care delivery....
The events ranged from wheelchair collisions to grabbing, hitting, and pulling behaviors that created safety concerns throughout the facility....
State surveyors documented that when staff discovered the resident missing at 3:35 p.m....
## Contaminated Linen Storage Areas During the inspection, surveyors documented concerning conditions in the facility's north hall clean linen closet....
Licensed Practical Nurse C reported separating the two residents multiple times between 5:30 p.m....
Fire safety training in nursing facilities extends beyond basic evacuation procedures....
These findings raise concerns about the facility's medication management systems....
The violations were classified under **F689**, which pertains to accidents and supervision, and resulted in a determination of **Substandard Quality of Care**....
The initial assessment documented no injuries and no pain complaints....
## Inadequate Fall Investigation Procedures Federal inspectors documented a pattern of incomplete fall investigations affecting multiple residents....
Regular bread poses multiple hazards for individuals with swallowing difficulties....
"I did not accept keys for that cart or anything," the nurse stated during the investigation....
A review of the resident's medical records confirmed none of these required elements existed....
Care plans serve as individualized roadmaps that guide all aspects of a resident's daily care, medical treatments, and therapeutic interventions....
During the March 27, 2025 inspection, facility leadership acknowledged they could not locate either required document in the resident's medical record....