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....
The insulin pen was found stored in a medication cart with a label showing it had expired according to manufacturer guidelines....
One resident experiencing chronic leg pain rated their discomfort at 7-8 out of 10 but received only ineffective Tylenol instead of prescribed Tramadol....
When residents needed specialized mental health care, the facility's social worker was responsible for making outside referrals....
Despite the fall and impact with the wheelchair, the incident was not reported to nursing staff or supervisors....
The carts contained prescription medications for resident treatments and remained accessible without any staff supervision....
The resident had scored a **3 out of 15** on the Brief Interview for Mental Status assessment, indicating severe cognitive impairment....
During an interview, R3 described being placed on a bedpan by staff and then waiting **four hours** before anyone responded to her call light for removal....
The inspection revealed multiple instances where beef was served for up to four consecutive meals, and poultry for three consecutive meals....
On March 9, 2025, R103 attacked another severely cognitively impaired resident (R83) three separate times within a 45-minute period....
Inspectors documented multiple breakdowns in the facility's response to this infectious disease emergency....
This omission proved critical, as the resident's condition deteriorated during her stay....
The facility neglected to create goals and interventions specifically designed to mitigate potential accidents, hazards, and the risk of drug overdose....
EDGERTON, WI - A comprehensive state inspection at Edgerton Care Center, Inc....
Three residents were identified as requiring enhanced precautions but receiving inadequate protection....
## Medical Risks of Unmonitored Psychiatric Drugs Antipsychotic medications carry serious health risks that require constant vigilance....
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....
On February 19, 2025, a nurse documented finding the resident's left leg "very red" with pitting edema and multiple blisters, one of which was open....