Latest reports, citations, and penalties from CMS data
The incident occurred on June 5, 2024, when physical therapy staff applied an e-stim device to a resident's right leg and left the room during treatment....
Despite these visible symptoms and an active prescription for Sinemet, the facility's April 2025 assessment omitted the neurological diagnosis entirely....
The violations centered around the facility's failure to recognize, investigate, and report abuse incidents as required by federal regulations....
This approach, known as person-centered care, aims to treat the root cause of behavioral symptoms rather than simply medicating them....
Despite this clear directive, nursing staff did not follow the facility's own emergency protocols....
**The resident missed a total of five doses over two days** - three doses on December 3rd and two additional doses on December 4th....
Another resident scheduled for bathing every Thursday and Sunday received only three baths over a 30-day period from mid-February to mid-March 2025....
Both residents had physician orders for fortified diets and nutritional assessments recommending continued fortification for weight maintenance goals....
On January 5, a family member informed facility staff that R1 had complained about a staff member being mean and rude....
However, when inspectors returned on March 18, they found the promised improvements had not been implemented....
During observation periods, all three licensed nurses monitored made significant errors that could have compromised resident safety and treatment outcomes....
This delay in reporting had serious consequences for the 66-year-old resident, who has type 2 diabetes with diabetic neuropathy and chronic kidney disease....
However, this critical safety measure was not added to the resident's official care plan, leaving multiple staff members unaware of the new protocol....
The resident was observed multiple times lying in bed, moaning with facial grimacing and labored breathing....
Staff members confirmed this setup was intended to prevent the resident from attempting to leave his bed....
The elevated temperatures resulted from a water heater thermostat malfunction....
The facility's Units B and C were particularly affected, with room temperatures ranging from 65 to 69 degrees....
When nursing staff discovered the inhalers during the inspection, they acknowledged the violation....
Inspectors found that safety protocols were not consistently followed, creating unnecessary risks for vulnerable residents....
The broken equipment had a sharp plastic edge protruding from the outer covering where the hard plastic had peeled away, exposing internal wiring....