Latest reports, citations, and penalties from CMS data
The violations are particularly concerning given that all affected residents had documented cognitive impairments and fall histories....
On February 8, 2025, a physical altercation occurred between two residents in a hallway near one resident's bedroom....
Inspectors found that licensed nurses failed to properly identify residents before administering medications, violating basic safety protocols....
The most concerning incident involved an activities assistant who incorrectly recorded a resident's meal intake....
Immediate jeopardy determinations are reserved for situations where residents face the risk of serious injury, harm, impairment, or death....
An acute care nurse found the resident "pushing on the exit door trying to get out" and stayed with her until facility staff retrieved her....
During the inspection, surveyors repeatedly observed call lights that were visibly activated but produced no sound to alert staff members in the hallways....
According to inspection records, the regulatory crisis began in late December 2024 when the facility's administrator position became vacant....
During interviews, the maintenance supervisor disclosed that several critical exit doors had their alarms routinely turned off during business hours....
The violations prompted emergency corrective measures and highlighted systemic breakdowns in resident safety monitoring....
Instead of following proper de-escalation procedures, Certified Nursing Assistant #41 picked up an ashtray and threw it at the agitated resident....
When state inspectors investigated the complaint, nursing staff were unable to locate the medication anywhere in the facility....
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....