Latest reports, citations, and penalties from CMS data
Posted schedules for January 25 showed only eight CNAs working the morning shift, six on the evening shift, and four during the overnight hours....
This represented a 7.01% weight loss, exceeding the clinical threshold of 5% that triggers heightened monitoring and intervention....
The inspection, completed July 10, 2024, followed a complaint investigation into the June 24 incident....
## December Immediate Jeopardy Period An immediate jeopardy situation occurred at the facility beginning December 20, 2024....
The Minimum Data Set represents a comprehensive assessment tool required by federal law for all Medicare and Medicaid-certified nursing facilities....
## Critical Training Deficiencies Identified The April 2025 federal inspection revealed significant gaps in the facility's abuse prevention program....
## Federal Oversight Process The Centers for Medicare & Medicaid Services conducted a complaint investigation at the facility on July 12, 2024....
to arrive for treatments beginning at 4:15 a.m....
The protective pad placed over the sheet was dry, indicating the soiled linens had been left unchanged from a previous shift....
Between the dates documented in the report, five residents on Team 3 tested positive for COVID-19....
This documentation failure revealed a systemic breakdown in the facility's ability to track resident whereabouts....
The facility's physician ordered a urinalysis with culture and sensitivity testing that same evening at 11:08 PM....
The violations centered on improper injection site rotation, administration of expired medications, and incorrect dosing schedules....
However, staffing records showed they were consistently short by 0.5 to 1 CNA across multiple shifts....
Thirty residents were supposed to be on EBP protocols, but inspectors found widespread non-compliance with safety requirements....
More critically, improper handling of controlled substances creates opportunities for diversion and makes accurate inventory tracking impossible....
However, inspectors found **no documentation** of these critical safety measures in the resident's medical record....
During the inspection, surveyors observed the resident's genital area was "red and raw" from the catheter trauma....
The most concerning finding involved Lorazepam Injectable, a controlled substance used to treat anxiety symptoms and prevent seizures....
The staff who ignored the emergency signal included the Director of Nursing, two licensed nursing personnel, and the Activities Director....