Latest reports, citations, and penalties from CMS data
The facility's own care plan, initiated on September 17, 2024, identified the resident's "behavior wandering into other resident's room" as a focus area....
The failure occurred when both the ignition control module and gas valve malfunctioned, requiring replacement parts that were not immediately available....
The incident occurred despite a hand washing sink being available at the nursing station....
The aide later confirmed she understood the resident required Enhanced Barrier Precautions but failed to follow the protocol....
During the inspection, surveyors observed flies directly landing on residents....
Despite these documented risk factors, facility staff failed to maintain adequate supervision....
When these systems fail, residents face potentially life-threatening delays in receiving help for medical emergencies, falls, or other urgent situations....
The resident then "leaned forward and slowly slid off the foot plate of the sit-to-stand," according to Staff C's account to investigators....
The violations occurred despite facility policies requiring physician orders and proper assessments before implementing any restraint measures....
The bathroom showed signs of significant deterioration and potential contamination that had been left unaddressed by facility maintenance staff....
Blood pressure readings help monitor cardiovascular health and medication effectiveness....
These violations posed immediate danger to vulnerable residents who depend on precise blood sugar control....
## Pattern of Licensing Oversights The inspection documented systematic failures in the facility's employee verification system....
Resident 18, who has diagnoses including schizophrenia and bipolar disorder, made inappropriate comments to her roommate, Resident 103....
Inspectors documented three separate medication errors that demonstrated systemic failures in basic safety protocols....
The resident required seven different medications to be crushed and administered through the gastrostomy tube....
These protocols extend beyond standard precautions and require specific protective equipment during high-risk procedures....
The resident, who had chronic obstructive pulmonary disease and chronic respiratory failure, had not had a bowel movement for two to three days....
"The wedges should be placed under the bed sheet and not under the mattress," acknowledged an LPN supervisor during the inspection....
Multiple residents reported waiting between one to two hours for help with toileting, personal hygiene, and other essential care....