Latest reports, citations, and penalties from CMS data
On July 23, 2024, inspectors observed the resident sitting in her wheelchair with her shirt off and breasts exposed while other residents passed by her room....
The resident's weight dropped from 154 pounds on February 8 to 143.2 pounds by March 9, representing a loss of nearly 11 pounds in just one month....
However, conflicting accounts emerged during the investigation that raised serious concerns about the circumstances of the injury....
When facility staff assessed the resident, they found no pulse or respirations and immediately began cardiopulmonary resuscitation....
The keys were also left unattended on the medication cart while a corporate nurse conducted routine checks for expired and unlabeled medications....
## Medication Monitoring Breakdown The most serious violation involved a 6-year resident who was prescribed daily aspirin following a stroke....
The incident involved two residents sharing a room, both requiring maximal assistance with daily activities due to severe cognitive impairment....
Inspectors observed multiple instances where staff contaminated their gloves and continued food handling without changing them....
Snellville facility administered incorrect oxygen levels and failed to maintain clean equipment filters, putting residents at serious respiratory risk....
The current violation centers on the facility's failure to ensure that a registered dietician's specific recommendations were properly administered as ordered....
Stand lifts are mechanical devices used to safely transfer residents with mobility limitations from beds, toilets, and wheelchairs....
The resident, who was on aspiration precautions and required assistance with meals, began vomiting while lying in bed after lunch....
This represents a critical breakdown in the nursing home's internal oversight system designed to identify and correct compliance issues....
Inspectors reviewed the facility's policy dated December 2024, which establishes the foundation for all pharmaceutical services within the nursing home....
In one of the most concerning cases, a resident received six doses of haloperidol at 20 milligrams instead of the prescribed 4 milligrams total daily dose....
**Resident 74** was observed with the left upper bed rail up, even though a May 30, 2024 assessment determined no bed rails were needed....
## Medical Risks of Improper Electrical Setup Extension cord misuse in healthcare settings poses significant risks beyond typical household hazards....
The nursing home set March 5, 2025, as its target date for full compliance with these safety measures....
No justification was documented for the significant delay in this case....
Staff A attempted the transfer alone despite **clear instructions posted inside the resident's closet door** and verbal warnings from the resident's spouse....