Latest reports, citations, and penalties from CMS data
According to the inspection narrative, the facility initiated a "Code W" elopement protocol and began searching the building and surrounding perimeter....
## Medical Context and Risk Factors Falls in nursing home residents with severe dementia carry significant medical risks....
Both incidents occurred during routine transfers that failed to follow established safety protocols....
**"I should not have left the card of medicine on top of the medication cart,"** acknowledged one nurse when confronted about the violation by inspectors....
These evaluations are crucial for ensuring appropriate placement and care coordination for vulnerable populations....
Documentation showed the resident missed these medications on July 4th and 5th, 2024, with some medications missed at multiple scheduled times....
On February 9, 2025, Resident 392 physically struck Resident 42 in their shared room....
Critical documentation gaps emerged during the investigation....
Both medications are formulated as extended-release to provide steady therapeutic levels throughout the day....
This verbal-only policy structure represents a significant oversight in resident protection protocols....
According to the inspection report, the resident received three doses of the long-acting medication between December 21 and December 29, 2024....
The resident, identified as Resident 36, experienced a measurable decline in activities of daily living capabilities between October 2024 and January 2025....
The perpetrator had removed Resident #25's adult brief and forcefully pulled out his catheter, causing visible physical harm....
Additionally, four nursing assistants lacked training in PTSD, SUD, GDR, trauma informed care, and fall management....
The original plan included only basic interventions: a physical therapy evaluation and following the facility's fall protocol....
This staffing gap represents a fundamental breakdown in infection control infrastructure....
The violations were classified as "immediate jeopardy" - the most serious level indicating potential for serious injury or death....
During interviews, nursing staff described the impact of these shortages....
The incident exposed multiple breakdowns in the nursing home's drug security protocols and raised questions about patient safety oversight....
During the three-day inspection period from January 15-17, 2025, surveyors observed the resident with cigars within arm's reach on multiple occasions....