Latest reports, citations, and penalties from CMS data
The assistant director of nursing, when asked about it, said it was her responsibility to make sure those orders were carried out....
The citation, issued August 22, 2025, fell under a category covering quality of life and care....
Inspectors classified the scope as widespread, meaning this was not a single staff member cutting a corner on a single shift....
The deficiency was among nine violations documented during a complaint inspection at the facility....
The August 22 complaint inspection turned up the care planning failure under a category regulators call Resident Assessment and Care Planning Deficiencies....
The inspection report did not document that any resident was actually harmed, but inspectors determined there was potential for more than minimal harm....
The inspection report describes a specific protocol that was not being followed....
One of those deficiencies cut to the center of what a nursing home is supposed to do....
That phrase, "potential for more than minimal harm," is the floor of what triggers a formal citation....
The two men, identified in inspection records as Resident #2 and Resident #4, shared a room at the facility....
When inspectors sat down with the Director of Nursing on the morning of August 23, she confirmed both....
The inspection, completed August 25, 2025, was triggered by a complaint....
Level D is not a paperwork problem....
Potential for more than minimal harm....
It also found the facility had not properly employed or obtained the services of a licensed pharmacist....
The August 23 complaint inspection produced an Immediate Jeopardy finding under F0689, the federal standard governing accident hazards and resident safety....
The group either lacked the required members, failed to meet at least quarterly, or both....
The incident happened on August 6....
The deficiency, cited under federal tag F0580, was one of three violations inspectors documented during the August 25 complaint inspection....
Inspectors classified the violation as an isolated incident, meaning it affected a limited number of residents rather than representing a widespread pattern....