Latest reports, citations, and penalties from CMS data
The violations earned the facility an immediate jeopardy citation â the most serious level of harm â during an April inspection....
Two residents received improper pain management that violated basic medical protocols....
The problems stretched back to November 2024, when the facility's pharmacy delivery issues began....
Nye Summit switched Resident 7 from Elavil to Quetiapine on November 5, 2024, for a diagnosis of primary insomnia....
Three of those falls resulted in major injuries....
Resident 53 died after staff failed to properly monitor deteriorating vital signs and notify physicians about critical changes in condition....
The resident, identified in inspection records as R200, was found unresponsive in his bed at Roswell Center for Nursing and Healing on an evening in late 2024....
Resident 115 was found unresponsive at Sherman Oaks Health & Rehab at 7:20 p.m....
From 7:15 PM to 9:45 PM, two licensed practical nurses handled all resident care alone â medications, treatments, personal hygiene, and call bells....
Resident 67 tested positive for COVID on July 16 and remained in the same room with Resident 61, who tested negative....
The violations placed the resident at risk for hypoglycemia, seizures, coma and death....
The insulin error occurred April 19 when a licensed practical nurse gave the injection to the wrong resident after patients switched rooms....
The resident, identified as R50 in inspection documents, has claimed the facility's bird room as "her office" and aggressively defends her territory....
The maintenance director told inspectors during a July interview that some of the nursing home's plumbing is more than 100 years old....
The Director of Nursing acknowledged during a May 21 interview that Resident #17 lacked the required physician's authorization for oxygen treatment....
The improper testing method was just one of several kitchen safety violations inspectors documented at the 97-bed nursing home on West Bernardo Drive....
Resident #455, admitted with end-stage heart failure and anemia, had been placed under hospice care in late May....
The physician's orders specifically required weekly changes of respiratory supplies and filter cleaning....
When observed a second time, the aide extended the testing time to three seconds â still far short of manufacturer guidelines....
The June 8 fight erupted around 2 p.m....