Latest reports, citations, and penalties from CMS data
However, inspectors found **no documentation** of these critical safety measures in the resident's medical record....
During the inspection, surveyors observed the resident's genital area was "red and raw" from the catheter trauma....
The most concerning finding involved Lorazepam Injectable, a controlled substance used to treat anxiety symptoms and prevent seizures....
The staff who ignored the emergency signal included the Director of Nursing, two licensed nursing personnel, and the Activities Director....
During interviews, the DSS admitted she had started the required dietary manager course but failed to complete the certification process....
## Critical Delay in Emergency Care The violation occurred when a resident reported severe hip pain following a fall on November 17, 2024....
This classification requires facilities to implement immediate corrective measures to protect resident safety....
Despite this known behavior pattern, staff repeatedly placed the resident in a position that restricted mobility....
The facility's infection control failures extended beyond individual incidents....
QAPI programs are designed to systematically identify, analyze, and address care quality issues....
Twenty-two minutes later, they found him walking in a field approximately two blocks from the facility....
The violations affected the majority of residents reviewed who had pressure wounds, raising concerns about systematic care deficiencies....
The incident prompted immediate corrective actions and a comprehensive review of medication administration protocols....
The resident, who has a spinal cord injury at the thoracic level affecting T2-T6 vertebrae, was in his motorized wheelchair when the incident occurred....
The resident was found unresponsive in his wheelchair at 4:30 AM with blood sugar levels exceeding 500 mg/dl - more than five times the normal range....
Storage areas must be locked and access limited to authorized personnel only....
Staff also attempted to administer blood pressure medications when the resident's pressure was dangerously low at 97/41....
The resident's face appeared "reddish purple" with only a weak pulse detected and no visible breathing patterns observed....
On September 13, 2024, nursing staff documented escalating behavioral concerns....
She reported hearing nothing about a therapist appointment despite her request....