Latest reports, citations, and penalties from CMS data
The facility's own Situation Background Assessment and Recommendation form explicitly noted that the physician had not been contacted....
The violation affected Residents 10, 11, 50, 53, 62, 81, and 83—all individuals with documented swallowing difficulties requiring texture-modified foods....
The cognitive assessment revealed R1 scored a 3 on the Brief Interview for Mental Status, indicating severe cognitive impairment....
The delayed reporting represents a serious breach of protocol that could have prevented state authorities from conducting a timely investigation....
When two residents approached the medication cart, the nurse handed each a cup of medications from the top drawer without checking the electronic record....
Emergency medical personnel arrived to find no resuscitation efforts had been attempted by facility staff....
When asked about staff response times to his call bell, one resident stated he didn't have one....
Healthcare facilities implement enhanced barrier precautions because residents with invasive devices face significantly elevated infection risks....
When inspectors identify patterns linking multiple violation categories, it typically indicates organization-wide problems rather than isolated incidents....
Documentation revealed multiple instances where bathing care was either not provided or not properly recorded....
The failure to follow these protocols represents a breakdown in resident safety systems designed to protect vulnerable individuals....
When asked if he was choking, the resident nodded while struggling to breathe....
Additionally, the nurse documented administering a Mometasone Furoate inhaler that was never actually given to the resident....
When questioned, a certified nursing assistant acknowledged that placing all four side rails in the raised position constituted a restraint....
The inspection revealed that 26 of 27 residents did not receive proper screening to determine their eligibility for influenza and pneumonia vaccines....
During an initial facility tour on June 3, 2024, at 8:45 a.m., surveyors observed the resident lying in bed without the cervical collar....
Inspectors identified systemic failures in how staff assessed fall risks and communicated safety measures....
The investigation revealed a critical gap between the nursing home's monitoring procedures and actual care delivery....
The nurse subsequently admitted to borrowing the Lasix from another nurse - medication that belonged to a different resident entirely....
The facility had no RN staffing on December 2-3, 9-10, 16-17, 23-25, and 29-31, 2023....