Latest reports, citations, and penalties from CMS data
On the Oceanview unit, the most severe temperature violations occurred when the test tray was received 26 minutes after the food cart arrived....
One resident experiencing chronic leg pain rated their discomfort at 7-8 out of 10 but received only ineffective Tylenol instead of prescribed Tramadol....
The carts contained prescription medications for resident treatments and remained accessible without any staff supervision....
On March 9, 2025, R103 attacked another severely cognitively impaired resident (R83) three separate times within a 45-minute period....
The facility neglected to create goals and interventions specifically designed to mitigate potential accidents, hazards, and the risk of drug overdose....
Three residents were identified as requiring enhanced precautions but receiving inadequate protection....
Gastrointestinal bleeding represents a medical emergency that can rapidly become life-threatening without proper intervention....
These precautions were implemented due to the resident's feeding tube and chronic wound condition, both of which create elevated infection risks....
The consequences of delayed physician notification can be severe....
This can result in unnecessary deterioration of physical condition, increased risk of complications, and reduced quality of life....
This designation indicates conditions that pose an immediate threat to resident health and safety....
Hand hygiene between patient contacts is considered the single most important practice for preventing healthcare-associated infections....
The Director of Nursing confirmed that CNAs are responsible for serving food while dietary staff handle meal preparation and matching to dietary cards....
The regulatory framework requires nursing homes to establish and maintain comprehensive policies, procedures, and oversight mechanisms....
The facility's medication error rate reached **6.06%**, exceeding the federal standard requiring error rates below 5%....
More concerning, the facility administrator was not informed of the sexual abuse incident until February 4, 2025 - months after it occurred in September 2024....
The resident, admitted in September 2024 with diagnoses including diabetes and kidney disorders, had been placed on hospice care in January 2025....
However, she only redirected the resident back to his room without implementing the facility's protocol for one-to-one observation....
According to the inspection report, facility records showed recurring complaints about missing laundry from residents during council meetings....
The absence of a trained infection preventionist creates cascading risks throughout a nursing facility....