Latest reports, citations, and penalties from CMS data
The facility's medication errors included crushing extended-release medications that should never be altered....
One patient receiving hospice care for stage 5 kidney failure missed four fentanyl patch applications over 13 days....
Inspectors found two residents with pressure ulcers were not receiving the enhanced barrier precautions required by federal regulations updated in April 2024....
Despite having clear protocols in place, inspectors observed multiple instances where nursing staff failed to follow these critical safety measures....
The dietary manager acknowledged multiple instances of improper food handling that posed contamination risks to residents....
The resident had a deep wound reaching muscles, ligament and bone that required specialized care....
The individual was transported to the hospital emergency department for evaluation and returned to the facility five days later....
These precautions are specifically designed to prevent healthcare-associated infections in high-risk patients....
The error resulted in severe hypotension requiring emergency hospitalization and intensive monitoring....
## Critical Impact on Resident Safety Incomplete medical records create multiple safety risks for nursing home residents....
According to inspection findings, residents consistently experienced long delays when requesting assistance with fundamental daily care needs....
This oversight represents a fundamental breakdown in the medication management system that protects vulnerable nursing home residents with diabetes....
## Incident Details and Impact on Resident The incident occurred on April 22, 2025, when Resident 1 requested assistance to be repositioned in bed....
The violations centered on inadequate documentation of insulin administration for a resident with both diabetes and Parkinson's disease....
Resident 44 broke their hip on August 10, 2024, when they attempted to transfer from their wheelchair to bed without assistance....
Two residents with cognitive impairments experienced delays in receiving appropriate wound care protocols....
This created a dangerous scenario where, in the event of cardiac arrest, emergency responders would have conflicting information about the resident's wishes....
The nurse administered 4% lidocaine patches instead of the prescribed 5% strength to a resident requiring pain relief for both shoulders....
Emergency Medical Services transported the resident to the hospital at 7:25 am....
## Medication Storage and Labeling Failures Inspectors found serious medication management violations across multiple areas of the facility....