Latest reports, citations, and penalties from CMS data
This deficiency indicates systemic problems in the facility's ability to monitor and improve critical medical procedures....
The resident required substantial assistance with daily activities due to severe cognitive impairment....
The committee's inability to maintain oversight of medication safety protocols represents a breakdown in the facility's quality management structure....
Documentation shows the resident made sexually inappropriate comments to staff on June 8, with the behavior continuing and escalating over the following weeks....
## Complete Care Abandonment Captured on Video Surveillance footage from March revealed the shocking extent of the care abandonment at Jefferson Manor....
The BIMS scale ranges from 0-15, with lower scores indicating greater cognitive decline....
## Inconsistent Cleaning Schedules Documented The inspection revealed significant gaps between the facility's written policies and actual cleaning practices....
When questioned, the nurses acknowledged they should have worn proper PPE to prevent infection spread....
**Incontinence care** represents a critical aspect of nursing home care that directly impacts resident dignity and health....
However, the months-long delay in recognizing and addressing the trauma violated federal requirements for timely psychosocial care....
The facility's QAPI committee, responsible for monitoring and improving care quality, failed to maintain effective systems for ensuring regulatory compliance....
Second-degree burns affect deeper layers of skin and can cause significant pain, scarring, and complications requiring specialized wound care....
## Cold Food Service Prompts Resident Complaints The inspection began after multiple residents complained about food quality....
According to the Director of Nursing, one ulcer began as moisture-associated skin damage in April 2024 and progressed to a stage 3 ulcer....
## Freezer Contamination Risks Documented During a March 27, 2025 inspection, surveyors found significant ice buildup in the facility's food storage freezer....
Proper medication storage and labeling serves as the first line of defense against adverse drug events in long-term care settings....
**Resident #12**, an 89-year-old resident with dementia, presented a similar situation....
When told to stop, Resident #2 reportedly said, "She likes it." The incident occurred in the facility's secured dementia unit, where both residents lived....
## Dangerous Fall Pattern Emerges The most serious incident involved Resident #114, who experienced five separate falls over four days in early January....
One resident sustained a significant fall causing a right femur fracture with a possible patella fracture....