Latest reports, citations, and penalties from CMS data
The patient, identified in federal inspection records only as Resident 8, was taken to a general hospital after the fall....
Federal health inspectors cited the facility following a complaint investigation completed on August 25, 2025....
The incident happened on June 16, 2025....
"That is dead," the aide told an inspector....
The inspection was conducted on August 25, 2025, following a complaint....
Staff came running toward the yelling....
That resident had a urinary catheter....
Despite all of that, inspectors noted the resident scored a 15 out of 15 on a cognitive assessment administered in July 2025, the highest possible score....
The violation was classified at Scope and Severity Level D, meaning it was isolated in nature, with no actual harm documented....
None of those omissions were disputed....
That distinction matters less than it might seem....
The deficiency was classified as widespread, meaning the breakdown wasn't isolated to one unit or one patient....
The citation fell under regulatory tag F0804, which covers nutrition and dietary deficiencies....
The resident, identified in inspection records as Resident 202, had eloped from the facility....
The citation, issued August 26, 2025, fell under the category of quality of life and care deficiencies....
Inspectors noted the violation affected many residents....
Inspectors rated the training failure as widespread, meaning it wasn't isolated to one unit or one shift....
The director of nursing said it plainly: a sitter should have been assigned before the fourth fall....
The deficiency was one of 20 cited during the inspection....
A single cold meal on a single afternoon is a bad day....