Latest reports, citations, and penalties from CMS data
The resident, who had dementia and exhibited physical behaviors, rejection of care, and wandering, began hospice services on January 17, 2025....
Medical records showed the resident's weight began declining sharply in April, with an 8-pound loss in just one month between April and May....
The April 5 incident was particularly serious - an unwitnessed fall that resulted in a head laceration and emergency room evaluation....
The violations center on the facility's inability to follow through on promises made after a previous citation in June 2024....
When the staff member called out to Resident 2 and asked what they were doing, the perpetrator stopped and walked back to their own bed....
The Nurse Manager did follow proper hand hygiene protocols between steps but failed to don the required gown before beginning the procedure....
Similarly, Resident #42 displayed symptoms starting April 26, progressing to a "congested cough and hoarse voice" by April 29....
This fundamental breach of medication management protocols creates significant health risks....
The violations affected up to 43 residents who regularly ate in the facility's dining areas....
The kitchen failed to maintain basic food labeling and dating protocols, with multiple items stored without proper identification or expiration dates....
According to the inspection findings, the resident's speech therapist had evaluated her multiple times between admission and discharge from therapy services....
The fall resulted in immediate transport to the emergency room for treatment of injuries sustained in the accident....
## Two-Hour Search Ends with Resident Found in Dangerous Location The facility initiated a "Dr....
Both drugs carry specific manufacturer warnings against crushing due to their special formulations....
The Wanderguard system functions as an electronic monitoring device that alerts staff when residents approach exit doors....
## Medical Consequences of Delayed Reporting Prompt communication of diagnostic results is a cornerstone of quality medical care in nursing home settings....
This delay in medical communication potentially exposed the resident to serious diabetic complications....
The most concerning discoveries occurred in areas where vulnerable residents spend significant time, including bedrooms and dining spaces....
Two residents with long-term IV access were affected by these violations, which inspectors classified as having potential for actual harm....