Latest reports, citations, and penalties from CMS data
The March 12, 2025 inspection revealed widespread failures in food safety, infection control, and staff training that put the facility's 91 residents at risk....
This ensures that medical interventions can be ordered promptly, potentially preventing serious complications or death....
The facility's failure to meet these standards represents a fundamental breakdown in basic medical care....
These machines deliver pressurized air to keep airways open during sleep, making proper maintenance critical for patient safety....
This violation represents a critical gap in the medical oversight system that nursing homes are required to maintain....
Her February 7 Braden scale score of 18 indicated she was at high risk for pressure ulcer development, making prompt wound care essential....
The incident prompted an immediate investigation and comprehensive review of transfer safety procedures throughout the facility....
The documentation error was confirmed when inspectors observed the resident in bed with oxygen flowing through a nasal cannula on March 26....
The most concerning case involved a resident with metabolic encephalopathy who sustained a leg wound that went untreated for over a week....
The facility's inspection protocol for bed frames, mattresses, and safety rails was fundamentally flawed....
Resident #20, who has functional quadriplegia, was prescribed Heparin sodium injections twice daily as a preventive measure....
Insufficient lubrication can lead to corneal damage, increased infection risk, and progressive deterioration of eye health....
Records showed that **wound care was missed for over 48 hours** during a February weekend....
Effective communication is fundamental to safe healthcare delivery....
When these committees fail to function effectively, residents face increased risks of medical errors, safety incidents, and substandard care....
Over the next five months, the facility documented six separate falls, all occurring in the resident's room while he was unsupervised....
Despite having a documented fall prevention plan, inspectors found the facility repeatedly implemented the same ineffective interventions after each incident....
The facility's failure to implement these systems left vulnerable residents without adequate protection....
This regulatory gap occurred when the previous interim administrator's licensing and contract renewal plans fell through in late December....
One resident, identified as R348 in the report, had functional abilities that were completely omitted from their care plan....