Latest reports, citations, and penalties from CMS data
On February 4, 2025, the facility's administrator received a report that CNA #1 had been physically rough with a resident during a transfer attempt....
The incident involved two residents with significant mental health diagnoses....
during a March 2025 inspection, raising concerns about the facility's ability to maintain accurate records and ensure resident safety....
This violation of federal regulation F655 represents a fundamental breakdown in the facility's care coordination system....
However, **no evidence existed that the serum level was ever drawn**, and neither the physician nor nurse practitioner followed up on the missing results....
The investigation revealed this staff member, hired on December 16, 2023, had not received the mandatory annual QAPI training within the required timeframe....
The resident required partial to moderate assistance with basic activities including toileting and bathing....
The severity of this incident cannot be overstated....
For example, the left lower quadrant was used for injections on February 22 at both 9:40 a.m....
The meal remained at room temperature for nearly three hours....
This service disruption directly impacted at least four residents who required essential blood work and diagnostic testing....
The facility demonstrated multiple failures in outbreak management....
The facility's medical records showed troubling gaps in monitoring....
The violations represented fundamental breakdowns in activities of daily living (ADL) assistance that nursing homes are required to provide....
During the inspection, surveyors discovered an opened Lispro Kwikpen insulin pen in Medication Cart Station 2 that had expired but remained in active use....
Their presence ensures residents receive appropriate medical oversight, particularly during critical situations requiring immediate clinical judgment....
Despite this known temperature failure, kitchen staff continued using vegetables from the compromised freezer to prepare meals for residents....
The wound was first documented on July 3, 2024, but **staff never measured the wound** and failed to track its progression over the following month....
Continuing an unauthorized antibiotic treatment creates significant risks....
The investigation revealed a pattern of basic care failures affecting numerous residents throughout the nursing home....