Latest reports, citations, and penalties from CMS data
The facility's medication error rate reached **6.06%**, exceeding the federal standard requiring error rates below 5%....
**Resident 41**, who was diagnosed with dementia, major depressive disorder, and schizoaffective disorder, exemplified this critical oversight....
More concerning, the facility administrator was not informed of the sexual abuse incident until February 4, 2025 - months after it occurred in September 2024....
During the first incident on May 20, 2024, at 1:30 a.m., the resident was discovered outside the facility at 2:34 a.m....
This represents a fundamental breakdown in medical care protocols that govern how nursing homes provide respiratory treatments to residents....
During this observation at 1:46 PM, two staff members were seen passing the unsecured cart before the responsible Registered Nurse returned and locked it....
The resident, admitted in September 2024 with diagnoses including diabetes and kidney disorders, had been placed on hospice care in January 2025....
Incomplete or inaccurate assessments can lead to several concerning outcomes....
When facilities fail to maintain adequate quality assurance programs, it can lead to systemic problems affecting multiple aspects of care delivery....
Similar patterns emerged with other residents....
This violation under regulation F656 indicates systemic problems with the facility's internal oversight mechanisms....
However, she only redirected the resident back to his room without implementing the facility's protocol for one-to-one observation....
When these systems fail, it can indicate broader organizational challenges that may affect multiple aspects of resident care and safety....
Inspectors found inadequate wound measurements, missing documentation details, and failure to implement individualized skin protection interventions....
This represents a gap of over 14 months without the mandatory training that ensures staff remain current on infection prevention protocols....
According to the inspection report, facility records showed recurring complaints about missing laundry from residents during council meetings....
These precautions are specifically designed to reduce transmission of multi-drug resistant organisms that can cause serious infections....
The situation became more concerning given the presence of wandering residents on the unit....
When these committees fail to function effectively, facilities lose their primary mechanism for continuous improvement and resident protection....
The absence of a trained infection preventionist creates cascading risks throughout a nursing facility....