Latest reports, citations, and penalties from CMS data
According to the inspection report, **CNA 2 served as a translator when the resident became agitated and complained that CNA 1 was rough during care**....
The incident, which occurred around 6:15 p.m., resulted in facial lacerations and a painful hematoma on the resident's back....
The violations centered on the facility's failure to ensure that practitioners entered orders directly into the EMR system as required by federal regulations....
The March 12, 2025 inspection revealed widespread failures in food safety, infection control, and staff training that put the facility's 91 residents at risk....
This ensures that medical interventions can be ordered promptly, potentially preventing serious complications or death....
The incident prompted an immediate investigation and comprehensive review of transfer safety procedures throughout the facility....
Effective communication is fundamental to safe healthcare delivery....
Despite having a documented fall prevention plan, inspectors found the facility repeatedly implemented the same ineffective interventions after each incident....
Inspectors observed staff members failing to follow basic sanitization protocols during routine medical procedures....
During the inspection, a registered nurse was observed providing wound care to a resident who required enhanced barrier precautions due to a urinary catheter....
The facility's own assessment indicated a need for 12-18 nursing assistants per day to properly care for an average census of 109 residents....
## Serious Medication Security Violations The most concerning findings involved **medication cart security breaches** throughout the facility....
The bathing schedule showed concerning gaps, including the entire month of August 2024 and January 2025 when no showers were documented at all....
Federal inspectors observed nursing staff using the same glucose meter on multiple diabetic residents without proper disinfection between uses....
Multiple residents reported waiting **30 minutes to over an hour** for their call lights to be answered, creating serious health and safety risks....
The violations affected staff across multiple departments, including certified nursing aides, housekeeping, and maintenance personnel....
On October 3, 2024, nursing staff discovered maggots in the resident's right heel wound during a routine dressing change....
Three of these individuals had been employed in nursing roles since 2021, while two others had worked without proper licensing since 2023....
Despite this nurse providing a written statement about what she observed, facility administration conducted no thorough investigation....
The inspection revealed systemic breakdowns in basic safety protocols affecting multiple areas of resident care....