LOUISVILLE, KY- R1 sustained a fall, the facility failed to ensure that the resident received necessary follow-up, including implementation of physician orders for bilateral lower extremity. R1 required surgery and 10 hospital stay.

HOUSTON, TX- Facility failed to ensure the resident environment remained free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents.

GAINESVILLE, GA- R159 was emergently transferred to the hospital, where she expired from complications related to the facility’s failure to notify the resident’s physician of her change in condition.

SAVANNAH, GA- R572 was on a puree diet but was provided a sandwich on 11/12/2024 which resulted in her choking death.

THOMASVILLE, GA- Resident with a history prior to his admission of suicide attempts, given a cowbell instead of call light. Facility failed to implement care plan interventions.