Latest reports, citations, and penalties from CMS data
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....
The incident occurred despite the resident having a care plan that explicitly identified them as high-risk for elopement, with a risk score of 20....
Despite these documented precautions, the magnetic lock system on the courtyard gate was left disengaged after routine lawn maintenance....
Medical records revealed that staff repeatedly documented concerning findings about the resident's dialysis access site between December 2024 and March 2025....
The resident's psychiatric medication was ordered to be administered at 9:00 PM daily, but staff failed to provide these doses....
Water at 127 degrees Fahrenheit can cause first-degree burns in just one minute of exposure....
When nursing staff initially observed the skin breakdown on March 14, multiple certified nursing assistants reported seeing the affected area....
The April 2025 inspection documented improperly installed and maintained bed equipment throughout the 159-bed facility, prompting emergency corrective actions....
Inspectors observed dried brown smears on bathroom walls near light switches and on bedside commodes, which facility staff confirmed was fecal matter....
The violations affected multiple residents and created risks for medication errors, untreated medical issues, and deteriorating health conditions....
Personnel records examined during the inspection showed Cook D's initial dementia training occurred shortly after their hire date of December 16, 2023....
Long, untreated toenails in elderly residents create significant health risks beyond discomfort....