Latest reports, citations, and penalties from CMS data
The Activities Director witnessed the assault, stating she "just stepped out of my office when I saw the incident" of R505 touching R504's chest....
Records showed the sacral wound measured 4.5 cm in length, 1.2 cm in width, and 2 cm in depth at the time of inspection, with exposed bone and tissue visible....
The policy states that trained rescuers should provide chest compressions and ventilations with the correct 30:2 ratio....
The CNA reported that between 2:00 PM and 4:00 PM, and again after supper, the facility frequently operated with just two aides for the entire main area....
For a resident with documented seizure disorder and HIV disease, missing anti-seizure medication creates compounded risks....
When nursing homes operate without sufficient staff, residents face immediate risks....
The CNA interpreted the gurgling sounds as the resident "tasting his food" and continued feeding despite these warning signs....
Federal regulations require nursing facilities to immediately report all allegations of abuse to the administrator and state agency....
The Clinical Manager admitted to inspectors that the facility "forgot to act upon" the pharmacist's recommendation to review the medication's appropriateness....
When the resident expressed her preference not to receive assistance from male staff, the CNA failed to notify anyone else about the resident's care needs....
Despite this clear indicator, nursing staff failed to develop the required care plan for fall prevention....
Despite the seriousness of this physical assault, investigators found the facility's response fell far short of regulatory requirements....
At 1:20 AM, a certified nursing assistant discovered the resident sitting on the floor near their bed, having fallen while attempting to get up unassisted....
Over the next 30 minutes, staff separated the residents repeatedly....
Pre-popping medications makes verification of these critical safety checks impossible....
The violation occurred when multiple staff members responded to a Code Blue alert but failed to correctly identify which resident required assistance....
When maintenance staff attempted cleaning with dish soap and an aqua-colored solution, inspectors noted these products were inadequate for proper sanitization....
## Prolonged Neglect of Basic Hygiene Needs The most troubling finding involved a paraplegic resident who required complete assistance with incontinence care....
Despite CPR efforts and emergency transport to the hospital, the resident experienced severe brain damage from oxygen deprivation....
Records showed the resident's referral documentation from her previous facility explicitly noted a suicide attempt just weeks before her transfer....