Latest reports, citations, and penalties from CMS data
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....
During interviews, the maintenance supervisor disclosed that several critical exit doors had their alarms routinely turned off during business hours....
When state inspectors investigated the complaint, nursing staff were unable to locate the medication anywhere in the facility....
The facility's medication error rate reached **16 percent** - more than three times the maximum allowable rate of 5 percent established by federal regulations....
The most concerning case involved a resident with a left shoulder fracture who experienced an eight-month delay in follow-up orthopedic care....
When patients become anxious, they may fight against the ventilator, leading to inadequate oxygenation and cardiac stress....
The incident occurred on June 5, 2024, when physical therapy staff applied an e-stim device to a resident's right leg and left the room during treatment....
The violations centered around the facility's failure to recognize, investigate, and report abuse incidents as required by federal regulations....
Despite this clear directive, nursing staff did not follow the facility's own emergency protocols....
The resident was observed multiple times lying in bed, moaning with facial grimacing and labored breathing....
The facility's Units B and C were particularly affected, with room temperatures ranging from 65 to 69 degrees....
When nursing staff discovered the inhalers during the inspection, they acknowledged the violation....
The January 2025 inspection also revealed that life-saving equipment was not maintained in working condition during a medical emergency....
On November 14, 2024, **Resident #2 experienced a severe choking episode while eating peanut butter crackers in the facility's communal living room**....
However, the program lacked proper oversight mechanisms required by federal regulations....
Additionally, two CNAs who had been employed for years had not undergone required re-fingerprinting under the state's Rap Back system....
This successful resolution demonstrates the effectiveness of proper quality management systems in nursing home operations....