Latest reports, citations, and penalties from CMS data
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....
## Missing Physician Orders Create Safety Risks The lack of organized medical records extended to critical physician orders....
The previous DON had departed several months earlier, leaving other staff members to assume portions of the critical leadership role's responsibilities....
The agreement waives the resident's right to pursue legal action through the court system....
Pureed diets are prescribed for residents with dysphagia or swallowing disorders, conditions common in nursing home populations....
However, inspection records reveal these critical interventions were not consistently implemented....
Additionally, the position requires one year of supervised social work experience in a healthcare setting working directly with individuals....
The remaining 105 residents received nutrition through feeding tubes....
The inspection resulted in documented violations of federal nursing home regulations....
## Critical Communication Failures Investigation revealed concerning gaps in staff knowledge regarding the resident's care preferences....