Latest reports, citations, and penalties from CMS data
Multiple staff members told inspectors during interviews that afternoon that they had just received emergency training on door security protocols....
The incident at AVIR at Lindale occurred around 5:17 or 5:22 AM, based on time stamps from video provided by the resident's family or caregiver....
The incident involved Resident #3, who fell on June 16, 2025, at Mission Valley Nursing and Transitional Care....
Federal inspectors found the violation during a complaint investigation completed October 29....
But administrators later told inspectors they couldn't tell from their own paperwork where the man actually went....
The resident appealed the discharge and won....
The resident, identified only as Resident #3, was admitted with shortness of breath and congestive heart failure....
Federal inspectors found Green Hill failed to honor dietary preferences for Resident #4 during a complaint investigation in late October....
The COTA informed the licensed practical nurse assigned to the patient's care, but the chain of communication stopped there....
The LPN confirmed seeing the broken tiles but stated, "I've never noticed that....
Resident #1 scored 6 out of 15 on a cognitive assessment in April, indicating severe mental impairment....
LPN #1 was covering medication duties for another nurse who had gone on break when Resident #2 complained of a headache around 2:30 PM....
The resident was subsequently hospitalized with sepsis....
Housekeeper B witnessed Resident #4 running through the facility while pushing Resident #6 in his wheelchair around corners and through hallways....
The October incident at Golden Years Center for Rehab and Healthcare began when LPN D helped a certified nursing assistant lay Resident #13 down after lunch....
"This has been going on for over three months." She had finally threatened to report the facility if conditions didn't improve....
CNA #3, who was operating the van, told inspectors she had not received training for the safe use of the securement system....
The resident at Hartley Nursing and Rehab was sent to an apartment on December 3rd....
Nurses documented giving the lower 5mg dose on the medication administration record at 12:37 AM and 7:15 AM that day....
The resident was admitted to the nursing home on November 11, 2023....