Latest reports, citations, and penalties from CMS data
The incident came to light when a passerby noticed someone walking up a hill who appeared to be a facility resident and alerted staff at 4:15 PM....
**Resident #34** was scheduled to receive eight different medications at 8:00 AM and 9:00 AM but only received three....
**The resident provided a written statement saying "I do not want her again....
The resident's care plan specifically mandated that staff "inspect his skin before and after applying the AFO" and conduct weekly skin assessments....
## Three Falls in Three Days The incident sequence began March 15 when the resident rushed to a shared bathroom without his walker....
The incident occurred on February 11, 2025, at 1:04 p.m....
The immediate jeopardy designation indicates conditions that pose an immediate threat to resident health and safety....
During the 4:55 AM medication administration, the nurse wore only disposable gloves but failed to don the required protective gown....
This reading, documented at 4:16 PM by medication aide MA C, represents a hypertensive crisis level that requires immediate medical attention....
The incident occurred on March 4, 2025, when the resident exited the facility at 5:09 AM through the front door....
Internal facility audits confirmed these missed treatments, yet administrators remained unaware of the widespread service gaps....
A mental health worker attempted to de-escalate the situation, but the resident pushed the staff member....
One resident with a urinary catheter had the drainage tubing dragging on the floor while using a wheelchair....
## Critical Kitchen Equipment Out of Service The inspection revealed that essential food preparation equipment was either malfunctioning or in poor condition....
## Critical Seizure Event Details On the day of the seizure, a nursing alert documented the frightening medical emergency....
Facilities must establish written policies and procedures for medication administration and ensure all staff members follow these protocols consistently....
The resident had been receiving the powerful narcotic pain medication at least five times daily to manage breakthrough pain not covered by his Fentanyl patch....
The Activities Director witnessed the assault, stating she "just stepped out of my office when I saw the incident" of R505 touching R504's chest....
Records showed the sacral wound measured 4.5 cm in length, 1.2 cm in width, and 2 cm in depth at the time of inspection, with exposed bone and tissue visible....
The policy states that trained rescuers should provide chest compressions and ventilations with the correct 30:2 ratio....