Latest reports, citations, and penalties from CMS data
According to the Nursing Home Administrator, proper staffing levels should include **one cook and three dietary aides for each shift**....
According to the inspection report, staff used a "shower or toilet" sling rather than the standard transfer sling required for bed transfers....
The resident remained on a regular diet with no nutritional modifications despite consuming only **26-75% of meals**....
However, the medication was never transcribed into the facility's medication administration system and was therefore never given to the resident....
According to inspection records, the facility experienced a period of non-compliance that was later resolved through corrective measures....
In June 2024, eight of 23 treatment opportunities for the heel wound were not completed, and six of 11 opportunities for the knee wound were missed....
According to the inspection narrative, R136 was assessed as cognitively intact but completely dependent on staff for all activities of daily living....
According to treatment records, when the resident's catheter became blocked on February 1, 2025, nursing staff replaced it—but used the wrong equipment....
These protocols are specifically designed to prevent the transmission of multi-drug resistant organisms between vulnerable residents....
The same issue appeared in the November 2024 report....
The facility's treatment systems failed at multiple levels, creating serious risks for vulnerable residents requiring specialized wound management....
The one-star staffing designation reflects more than just numbers on a spreadsheet....
During this process, the resident's head reportedly made contact with the door frame of his room....
The bag remained accessible to residents with cognitive impairments who regularly wandered the hallway....
When two residents approached the medication cart, the nurse handed each a cup of medications from the top drawer without checking the electronic record....
Emergency medical personnel arrived to find no resuscitation efforts had been attempted by facility staff....
Healthcare facilities implement enhanced barrier precautions because residents with invasive devices face significantly elevated infection risks....
The failure to follow these protocols represents a breakdown in resident safety systems designed to protect vulnerable individuals....
Inspectors identified systemic failures in how staff assessed fall risks and communicated safety measures....
The nurse subsequently admitted to borrowing the Lasix from another nurse - medication that belonged to a different resident entirely....