Latest reports, citations, and penalties from CMS data
The first documented blood sugar reading didn't occur until June 4 at 7:44 PM, when it measured 201 mg/dL - well above normal levels....
The resident's responsible party reported being at the facility around 5 p.m....
During a March 7, 2024 survey, inspectors had cited the facility for improperly storing and labeling medications....
Inspectors found that nursing staff repeatedly failed to follow physician-ordered protocols for insulin administration and blood sugar monitoring....
Similarly, Resident 39's annual assessment dated January 1, 2025, was still not completed by February 6, 2025....
According to the inspection report, this transition created dangerous gaps in medical coverage that lasted over a month....
When investigators reviewed Resident 29's medical records, they found the signed consent form but no documentation that the vaccine was ever administered....
These individuals may wander, fall, become agitated, or engage in behaviors that could harm themselves or others....
The resident's medical assessment showed a BIMS (Brief Interview for Mental Status) score of 4, indicating severely impaired cognition....
June showed similar patterns with AM temperatures recorded just 3 out of 30 days and PM temperatures documented only 2 out of 30 days....
This created dangerous delays during critical moments when every second matters for patient survival....
The Medical Director documented this incident, which created substantial fire hazards throughout the facility....
This represents a fundamental breakdown in the nursing home's internal oversight system designed to identify and resolve patient care problems....
Federal regulations require facilities to immediately notify physicians and family members when residents experience significant changes in condition....
The MDS assessment system serves as the foundation for determining appropriate care levels and Medicare reimbursement rates for nursing home residents....
The incident occurred in February 2025 when the CNA disregarded established protocols....
The violations occurred despite facility policies requiring all medications to be stored in locked compartments inaccessible to residents and visitors....
The resident was observed moaning, shouting, and grimacing during routine care activities like repositioning and personal care....
The situation became so concerning that it was **reported to the sheriff's office** for investigation....
According to inspection records, the facility had only one full-time cook and one part-time cook for day shifts, with no dedicated cook for evening hours....