Latest reports, citations, and penalties from CMS data
These regulations ensure facilities maintain minimum standards to protect vulnerable elderly populations....
The violations occurred during both 2023 and 2024 reporting periods....
## Paint Brush Food Preparation Violations The most egregious violation involved kitchen staff using paint brushes to prepare food for residents....
This comparison revealed the significant dosing discrepancy that facility staff had missed during the admission process....
The facility's own policy, revised in November 2023, clearly outlined these requirements....
A resident with severe cognitive impairment and dementia was taking multiple medications that the facility's pharmacist identified as problematic....
The medications were labeled with the resident's name but came from an outside pharmacy, violating facility policies....
The resident had a 7.5 size tracheostomy tube in place, but facility records incorrectly indicated it was a 6.5 size....
Any changes in a resident's condition or oxygen needs should be immediately reported to the attending physician for potential order modifications....
Normal oxygen saturation ranges from 96 to 100 percent....
On August 13, 2024, inspectors observed a registered nurse hanging IV fluids for the resident without wearing the required protective gown....
Within days of admission, staff completed a PHQ-9 depression screening that revealed a score of 17 - indicating moderately severe depression symptoms....
The dirty laundry area contained a large bin with an askew lid that was full of dirty laundry, some of which was unbagged....
A colleague who witnessed the incident reported that the CNA used the resident's personal beard shaver to perform the grooming....
## Medication Storage and Safety Failures Federal inspectors documented serious medication management issues throughout the facility....
The facility holds monthly QAPI meetings with quarterly participation from the medical director and pharmacist, as required by regulations....
After removing the old dressing and cleaning fecal matter from the resident's anal area, the nurse changed gloves but failed to sanitize hands between steps....
The violation came to light when another nursing assistant reported seeing the post on the offending employee's TikTok account....
The nurse had set the IV flow regulator to 200 ml/hr instead of the prescribed 135 ml/hr - a significant deviation that could cause harmful side effects....
The review process evaluated insulin administration protocols, physician orders, and compliance with prescribed treatment regimens....