Latest reports, citations, and penalties from CMS data
The incident revealed multiple breakdowns in communication and medical care that put the resident at significant risk....
When investigators returned nearly an hour later, the temperature remained at the same unsafe level....
Licensed Vocational Nurse 1 (LVN 1) completed the transfer form but failed to document whether or when the resident's emergency contact was notified....
Care conferences are mandatory meetings where healthcare teams, residents, and families discuss treatment plans, goals, and care needs....
The incidents involved taking residents' walkers, pushing residents, punching, spitting, and **knocking pictures off walls to throw them**....
## Medication Management Failures The facility faced significant citations related to proper medication administration and monitoring....
Inspectors observed three separate incidents where nursing staff provided direct care to residents without proper hand sanitization....
Documentation shows the medication was administered inappropriately on March 3, March 4, March 15, March 19, May 9, and May 11, 2025....
In one case, a low air loss mattress designed to prevent pressure sores was set at 550 pounds for a resident who weighed only 138 pounds....
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....