Latest reports, citations, and penalties from CMS data
When these oversight systems fail, residents face increased risks of accidents, medication errors, infections, and other preventable complications....
During multiple observations over two days, surveyors found the resident's fingernails severely overgrown, dirty, and causing him physical pain....
Additionally, the nurse forced medications through the feeding tube using a syringe plunger rather than allowing gravity flow, which is the accepted standard....
The resident, identified as Resident 48, was a cognitively intact individual with complete paraplegia who required extensive assistance with daily activities....
Care plans serve as essential roadmaps that guide daily treatment, medication administration, and therapeutic interventions for each resident....
During the inspection, surveyors observed the resident experiencing pain during care, stating "it hurts!" when nursing assistants cleaned the affected areas....
The resident, who has multiple complex medical conditions including dementia, muscle wasting, and a history of stroke, was hospitalized at 3:22 a.m....
This oversight represents a significant gap in person-centered care, as effective communication forms the foundation of safe nursing home operations....
This violation represents a significant breakdown in the facility's internal oversight systems designed to ensure quality care for residents....
The facility failed to implement proper wound care orders, provide a specialty mattress, or conduct required weekly skin assessments....
The violation involved a resident who had been diagnosed with both bipolar disorder and major depressive disorder....
Critically, **the administrator was not made aware of the specific verbal threats** during the initial investigation, according to her own testimony....
The incident, which occurred around 6:15 p.m., resulted in facial lacerations and a painful hematoma on the resident's back....
One resident with pulmonary hypertension and high blood pressure reported receiving her 8:00 AM medications as late as 12:30 PM on multiple occasions....
The resident, identified as R1, had signed state DNR forms, active physician orders documenting DNR status, and was wearing a DNR bracelet on their left wrist....
The F 0679 citation typically relates to quality of care standards that nursing facilities must maintain to ensure resident safety and proper treatment....
For Resident 51, medication records showed insulin injections were administered to the same body areas repeatedly over several weeks....
During multiple observations over four days in April, inspectors found the resident lying in bed, moaning with facial grimacing and labored breathing....
The violations centered on the facility's failure to ensure that practitioners entered orders directly into the EMR system as required by federal regulations....
Resident 6, diagnosed with dementia and cognitive impairment, was receiving Quetiapine Fumarate for behavioral control without an accompanying care plan....