This just doesn't happen very often,

I found out this morning at 7:45 when I was called,

We felt we discharged this patient in a stable condition, and a surveyor, reviewer, thought differently,

This is an extreme action based on a case that was not even identified in their original complaint,

Despite those solid gains, improvement haven't come as far and fast as we would have liked, and the achievement gains remains disturbing.

You'll find some heartening and some sobering conclusions.