Latest reports, citations, and penalties from CMS data
## Documentation and Monitoring Failures The March 2025 inspection uncovered significant gaps in how the facility tracked and responded to resident falls....
The Administrator and Director of Nursing were formally notified of two immediate jeopardy citations on June 7, 2024....
The hospital's discharge documentation clearly listed Type 2 Diabetes in the patient's medical history....
However, the facility's own daily documentation told a different story....
The inspection revealed multiple failures in the facility's abuse reporting and investigation protocols....
The facility's treatment protocol called for cleaning the wound with Dakin's solution and applying Mesalt dressings with border gauze every day shift....
One long-term resident with a traumatic brain injury had a representative who consented to annual influenza vaccination in September 2023....
Despite multiple requests spanning over a month, the Social Services Director failed to follow through on finding alternative placement....
These protocols were designed to prevent the transmission of infectious microorganisms through food preparation and service....
The resident, identified as R128, had been admitted to the facility in August 2023 and required assistance with transfers from bed to chair....
The resident, identified in records as Resident #9, had a documented history of dementia, anxiety, and previous hip surgery complications....
The inspection report revealed that during the May 24, 2024 meeting, no Infection Preventionist attended....
This testing was essential to identify whether alternative, less costly antibiotics might effectively treat the infection....
The findings revealed a pattern of medication management deficiencies that could have serious consequences for residents with diabetes....
This pattern contradicted the facility's own policy requiring thorough investigation of all abuse allegations....
The Administrator, when interviewed the same day, agreed that staff should have updated the PASRR documentation following the new psychiatric diagnoses....
The incident occurred when a Certified Nursing Assistant (CNA) was turning and repositioning the resident, who grabbed onto the facility's bed remote control....
Within days of admission, staff documented that the resident had an unsteady gait, poor balance, and was at risk for falls....
The equipment remained improperly stored despite not being in active use....
The Director of Nursing acknowledged during the inspection that staffing shortages were visible on the schedule and represented an ongoing challenge....