Latest reports, citations, and penalties from CMS data
The resident, who required complete staff assistance for movement and changing of incontinence products, was observed at 12:19 p.m., 4:29 p.m., and 4:51 p.m....
When blood oxygen saturation falls below 90%, tissues and organs begin receiving insufficient oxygen, a condition called hypoxemia....
No documentation was provided before the inspection concluded....
Resident 37, diagnosed with Huntington's Disease and dementia, had documented behaviors of banging their head against walls and punching walls....
Controlled substances require strict monitoring because of their potential for abuse and dependency....
The administrator, identified as S1ADM in the report, acknowledged to inspectors that **a 51-minute wait for changing soiled clothing was unacceptable**....
The inspection revealed systemic breakdowns in basic safety protocols affecting multiple areas of resident care....
The inspection, conducted from February 24 through March 3, 2025, resulted in an immediate jeopardy declaration affecting all 72 residents at the facility....
The facility received deficiencies during inspections ending April 25, 2024, October 23, 2024, December 13, 2024, and most recently March 13, 2025....
During breakfast observation on May 20, inspectors witnessed Resident #52 actively swatting flies away while attempting to eat his morning meal....
The violation represents a fundamental breakdown in basic nursing care protocols that require prompt response to resident pain reports....
The violations involved improper handling of medical equipment and inadequate use of protective equipment when caring for vulnerable residents....
State inspectors documented the nurse removing medications from four different bubble packs and placing them in a medication cup without the resident present....
The most recent documented assault had occurred just weeks before the transfer....
The two residents involved had significant cognitive impairments that raised serious questions about their capacity to consent to sexual activity....
According to the inspection report, Resident 103 called the police that evening stating she felt unsafe in the facility after an interaction with CNA 1....
The dentist specifically documented that the resident needed referral to an oral surgeon for extraction of all remaining teeth....
During the inspection, Resident 47 described experiencing significant challenges due to staff's lack of understanding about PTSD....
The facility's Minimum Data Set Registered Nurse (MDS-RN) acknowledged the errors during an interview with inspectors at 10:34 AM that morning....
The facility submitted an Immediate Jeopardy Removal Plan on March 12, 2025, claiming the dangerous conditions had been addressed as of March 10....