Latest reports, citations, and penalties from CMS data
The case involved a resident with muscle weakness and osteoporosis who had been identified as at-risk for pressure injuries based on facility assessments....
One resident with diabetes was found with fingernails measuring approximately one inch long and jagged edges, with brown substances accumulated underneath....
Rather than retrieving the mechanical lift as specified in the care plan, the assistant proceeded with a manual transfer approach....
Twenty-two minutes later, the resident was located walking in a field roughly two blocks from the facility....
The ceiling above one resident's bed showed visible deterioration including a dent, cracks, and water staining....
However, a review of the resident's medication administration records revealed these critical recommendations were never implemented....
These services were deemed necessary to reduce mental health symptoms and provide essential supports for the resident's safety and wellbeing....
The resident's care plan, initiated in July 2023, acknowledged limited physical mobility related to pain, wounds, and deconditioning secondary to sepsis....
During testing on July 9, 2024, inspectors measured food temperatures on the last meal cart delivered to residents....
During that hospitalization, a urologist placed a stent in the resident's ureter to allow urine drainage....
Injuries of unknown origin represent critical red flags in long-term care settings....
On February 28, 2025, Resident 71 climbed out of bed and fell, sustaining a laceration to the left eyebrow that required emergency intervention....
The absence of this basic tracking for more than two weeks represents a fundamental breakdown in infection prevention protocols....
## Medication Administration and Storage Failures Inspectors documented several critical issues with medication handling that compromised resident safety....
Older adults are more vulnerable to environmental hazards due to age-related changes in thermoregulation, sensory perception, and mobility limitations....
These violations represented fundamental failures to protect residents from medication errors and potential harm....
Care plans serve as roadmaps for staff members, outlining specific interventions, monitoring requirements, and goals for each resident....
This modification was in place for multiple residents and had been standard practice at the facility for years....
The violations occurred during routine medication administration rounds and involved fundamental lapses in nursing protocols....
The resident, identified in the report as R2, was last observed by medication staff at approximately 3:00 PM....