Latest reports, citations, and penalties from CMS data
However, when questioned about qualifications, the DON admitted she lacked certification in infection control, as did the ADON....
The gap occurred because the facility had run out of the resident's ordered medication but failed to notify the prescribing provider about the shortage....
During a February 24 test tray evaluation, inspectors found that hot foods were being served well below safe temperatures....
Resident 1, who has dementia and major depressive disorder with psychotic symptoms, was creating disturbances that prevented her roommates from sleeping....
Many residents have weakened immune systems due to age, chronic conditions, or recent hospitalizations....
However, the subsequent response by licensed nursing staff failed to meet federal standards for basic life support provision....
**Resident 228** exemplifies the consequences of inadequate wound care....
The resident's air mattress was discovered to be set at 450 pounds, despite the resident weighing only 164.1 pounds....
Federal regulations require nursing homes to maintain water temperatures at no more than 120 degrees Fahrenheit to prevent burns and scalding injuries....
This citation emerged from complaint investigation IN00453866, indicating that concerns raised by external parties prompted the regulatory review....
Rather than pursuing alternative solutions or escalating the communication breakdown between providers, facility staff allowed the situation to continue....
This cross-contamination issue could have impacted 128 out of 133 residents who consume food orally....
Both employees were no longer working at the facility when the violations were identified....
The incident involved Resident 48, who was readmitted to the facility with complete paraplegia and essential hypertension and was receiving hospice care....
Embedded objects can cause serious complications including cellulitis, abscess formation, and systemic infection....
Proper assessment should include identifying environmental factors, interpersonal situations, or sensory experiences that may precipitate episodes....
Licensed Practical Nurse #7 consistently administered morning medications 45 minutes to over an hour late due to an overwhelming patient load of 28 residents....
During the inspection, surveyors found two white tablets in a clear plastic cup on her bedside table....
The problem became so persistent that residents filed formal grievances in December 2024 and again in February 2025....
One CNA, employed since November 2022, had not received the required annual abuse training during the 12 months prior to the inspection....