Latest reports, citations, and penalties from CMS data
## Facility Fell Short on Corrective Commitments The inspection centered on **F684**, a federal deficiency tag related to **quality of care** standards....
The witnessing CNA immediately left the room and reported what she observed to the on-duty nurse....
The first three doses were administered using the facility's emergency drug kit, but the supply ran out....
The facility's internal incident tracking told the story clearly....
The facility received a citation for **actual harm** under federal nursing home regulations....
The inspection revealed that the narcotic log book contained **no documentation that shift-to-shift counts had been completed at any time**....
Residents placed in secured units typically require that level of protection because they are at risk of wandering....
Inspectors documented a detailed, minute-by-minute account of what occurred between 4:01 PM and 4:15 PM that day....
When surveyors reviewed the resident's Order Summary Report, **no physician order for oxygen administration existed anywhere in the record**....
That care plan had been in place since February 2022 and was active at the time of the incident....
He was dependent on staff for all activities of daily living and used a wheelchair....
A review of bath records revealed the resident received **zero baths** from his mid-December admission through the end of that month....
The findings raised concerns about the facility's ability to protect medically vulnerable residents from foodborne illness and infection....
His physician's orders clearly documented full-code status with plans to discharge home....
Quality assurance programs serve as internal monitoring systems that track clinical outcomes, incident patterns, and care delivery metrics....
The resident, who had diagnoses including anoxic brain damage, hypertension, and disorientation, made statements to staff expressing suicidal thoughts....
On July 15, 2024, state surveyors found a resident lying in a fully reclined Geri-chair with a wheelchair wedged underneath the extended footrest....
R47 received nebulizer treatments four times daily with Ipratropium-Albuterol solution to manage chronic obstructive pulmonary disease and shortness of breath....
The deficiency resulted in severe weight loss, representing a significant decline in the resident's physical well-being....
This violation represents a critical failure in healthcare facility management....