Latest reports, citations, and penalties from CMS data
## Outbreak Response and Reporting Failures The outbreak began on May 2, 2025, when the first resident developed gastrointestinal symptoms....
The violations revealed systemic problems with staff training, food handling procedures, and equipment maintenance....
The room's door had no locking mechanism, and nursing staff on duty confirmed they did not possess keys to secure the area....
The nurse removed dressings from both of the resident's feet, then removed her gloves without washing or sanitizing her hands before putting on a new pair....
These residents required enhanced barrier precautions due to their indwelling medical devices, which significantly increase infection risk....
Swallowing difficulties, medically known as dysphagia, represent a serious health concern in long-term care settings....
Inspectors classified the violations under federal regulation F580, which governs medication administration procedures and safeguards in nursing facilities....
Pressure injuries, commonly known as bedsores, occur when sustained pressure restricts blood flow to the skin and underlying tissue....
The bag contained no labeling indicating the medication type, opening date, expiration date, or intended recipient....
On March 12, 2025, seven of 26 residents received their scheduled 9:00 a.m....
The findings revealed a pattern of incomplete or delayed hygiene services that left vulnerable residents in compromised conditions for extended periods....
## Pressure Injury Care Falls Short of Standards Inspectors identified systemic failures in pressure injury prevention and treatment affecting six residents....
Long, debris-filled nails create environments where bacteria and fungi thrive, significantly increasing infection risk....
## Insulin Administration System Breakdown Inspectors identified critical deficiencies in how the facility managed insulin medications for diabetic residents....
One resident prescribed gabapentin 800 milligrams four times daily missed 21 consecutive doses between May 8 and May 13, 2024....
Pressure injuries, commonly known as bedsores, require immediate and ongoing medical attention to prevent serious complications....
The incident involved allegations of staff misconduct that should have triggered immediate reporting to state authorities....
Despite this knowledge, a certified nursing assistant left him unsupervised on the patio during lunch service....
The resident had recently been hospitalized on a psychiatric hold for threatening to kill staff and blow up a hospital....
Federal regulations mandate that facilities investigate all injuries of unknown origin to rule out potential abuse, neglect, or mistreatment....