Latest reports, citations, and penalties from CMS data
The contradiction emerged during an October complaint investigation that revealed systemic failures in the facility's elopement prevention program....
Immediate jeopardy violations mean inspectors determined residents faced imminent risk of serious injury or death....
Federal inspectors found that both the charge nurse and assistant director of nursing assumed the other would make the required family notification call....
Resident #2 required regular dialysis treatments but often refused them, according to MD G, who treated her at The Colonnades at Reflection Bay....
Federal inspectors found the Shadow Creek Parkway facility violated care planning requirements during a complaint investigation completed October 24....
Federal inspectors found the facility failed to report or investigate three separate resident elopements between June 5 and June 21, 2025....
The inspection revealed a broader pattern of call bell failures throughout the facility....
The documentation failures occurred at least nine times across May and June 2025, federal inspectors found during an October complaint investigation....
The incident at Complete Care at Severna Park occurred on July 3 at approximately 9:35 AM during breakfast service....
The facility's own staff described a system where single certified nursing assistants were expected to handle dozens of residents through 11 p.m....
The resident, identified only as #2 in inspection records, was readmitted to Viera Del Mar Health and Rehabilitation Center from a hospital on August 20, 2025....
After working with the IV machine for several minutes, the nurse told the resident she needed to step out for assistance....
The resident's cognitive skills for daily decisions were rated as severely impaired in an August assessment....
Inspectors found four separate medication carts that failed to lock properly during their October investigation....
The October incident at Ashford Gardens exposed gaps in the facility's sign-out procedures for residents who choose to leave temporarily....
The October inspection found that Resident #5 had two bed rails installed on her bed without physician authorization....
Nobody at the nursing home noticed Resident #127 was missing until nearly two hours after the 8:55 PM escape on May 11, 2025....
The pharmacy didn't deliver the resident's medications until 10:04 AM the next morning, August 2....
The Director of Nurses confirmed to inspectors that staff had improperly transported soiled materials between resident rooms....
The resident, identified in inspection records as CR #1, left the facility during an afternoon shift change without staff knowledge....