Latest reports, citations, and penalties from CMS data
In both cases, the nursing home did not submit investigation results to the State Survey Agency within the mandatory five working days....
According to the inspection report, documentation gaps occurred on multiple dates across three months....
The resident had been admitted in December 2024 with diagnoses including cerebral palsy, Type II diabetes, and depression....
Resident #47 was missing 60 tablets of oxycodone/acetaminophen 5/325mg, while Resident #57 was missing 30 tablets of oxycodone 5mg....
A resident with ESBL infection remained in a shared room despite facility policies requiring private room placement when beds were available....
Facility records showed the patient's itching symptoms had resolved by June 2024, yet both medications continued to be administered through September....
The facility failed to meet federal standards for tracking and evaluating significant weight changes among residents....
Nursing facility failed to follow ordered care plans for resident hand splints, potentially compromising recovery outcomes....
Similarly, Resident 44's Zosyn medication label didn't match the physician's order....
WanderGuard devices function as electronic monitoring systems that alert staff when residents with cognitive impairment approach exit doors....
After completing the feeding, RN AA moved to another table and fed a fifth resident using the resident's own spoon....
Dialysis patients require specialized monitoring due to the complex medical risks associated with both the treatment and the access site....
The same nurse then handled a germicidal wipe to clean the glucometer without first applying gloves, creating multiple opportunities for cross-contamination....
The resident subsequently fell from the bed and became wedged in the narrow space between the bed and wall....
An eight-page vendor aging report showed outstanding debts totaling millions of dollars, with some bills unpaid for over 151 days....
Inspectors determined there was **insufficient auditing and oversight** of the earlier citation, indicating the facility's corrective measures were inadequate....
**The nurse was unable to administer morning medications or required water flushes** due to the equipment malfunction....
## Missing Critical Assessments The facility failed to complete mandatory nursing assessments for three residents during crucial care transitions....
The 76-year-old patient, who had been diagnosed with Alzheimer's disease and severe cognitive impairment, was unable to explain how the injury occurred....
The contaminated cup was then placed on the nursing station desk, further spreading potential infectious agents throughout the care environment....