Latest reports, citations, and penalties from CMS data
The Director of Nursing acknowledged during the inspection that staffing shortages were visible on the schedule and represented an ongoing challenge....
The inspection revealed deficiencies first documented in November 2018, with subsequent citations in November 2019, October 2022, and January 2024....
On July 8, 2024, at 3:07 p.m., surveyors observed the memory care dining room carpet littered with food debris....
The inspection focused on medication security procedures required under federal regulations....
Additionally, the oxygen flow was set at 3 liters—50 percent higher than the prescribed dose....
The incident occurred as staff members were transferring the resident back to her bedroom to provide care....
A second resident with a history of heart disease, ischemic cardiomyopathy, and previous myocardial infarction received only partial pneumococcal vaccination....
One resident reported lying in a urine-soaked brief for hours while waiting for staff assistance....
One resident recovering from COVID-19 in isolation received breakfast in a foam tray containing fried eggs, toast, and cream of wheat....
This designation indicates that while no actual harm may have occurred, inspectors documented conditions or practices that posed genuine risk....
The Administrator acknowledged that the facility would "start a QAPI" and planned to reevaluate after three months....
The inability to provide documentation represented more than an administrative oversight....
No emergency supplies were found in any location....
The facility incorporated this intervention into the resident's care plan for preventing skin breakdown, acknowledging the importance of this measure....
The patch was intended for the resident's roommate....
The oral antibiotic metronidazole was also missed on multiple occasions during the resident's stay....
An immediate jeopardy designation indicates conditions exist that could cause serious injury, harm, impairment, or death to residents at any time....
The resident's medical record revealed a pattern of escalating weight gain - a critical warning sign in heart failure patients....
According to a staff witness statement, R1 was seated next to R2 in the dining room when staff observed him inappropriately touching R2's breast and buttocks....
The inspection revealed gaps in the facility's assessment process for restraint use....