Latest reports, citations, and penalties from CMS data
When patients become anxious, they may fight against the ventilator, leading to inadequate oxygenation and cardiac stress....
However, the facility failed to arrange timely specialist consultation....
Despite having a care plan that specifically addressed pressure ulcer prevention, staff did not follow the established protocols....
The resident was immediately transported to the local hospital emergency department, where physicians discovered two significant lacerations....
The inspection focused on **Resident 3**, who was prescribed levofloxacin (Levaquin) 500mg daily for a urinary tract infection through a feeding tube....
When the resident asked the nurse to stop because it was causing pain, the nurse reportedly continued the procedure....
They required substantial assistance with daily activities and mobility due to their above-knee amputation....
The incident occurred on June 5, 2024, when physical therapy staff applied an e-stim device to a resident's right leg and left the room during treatment....
Despite these visible symptoms and an active prescription for Sinemet, the facility's April 2025 assessment omitted the neurological diagnosis entirely....
The violations centered around the facility's failure to recognize, investigate, and report abuse incidents as required by federal regulations....
This approach, known as person-centered care, aims to treat the root cause of behavioral symptoms rather than simply medicating them....
Despite this clear directive, nursing staff did not follow the facility's own emergency protocols....
**The resident missed a total of five doses over two days** - three doses on December 3rd and two additional doses on December 4th....
Another resident scheduled for bathing every Thursday and Sunday received only three baths over a 30-day period from mid-February to mid-March 2025....
Both residents had physician orders for fortified diets and nutritional assessments recommending continued fortification for weight maintenance goals....
On January 5, a family member informed facility staff that R1 had complained about a staff member being mean and rude....
However, when inspectors returned on March 18, they found the promised improvements had not been implemented....
During observation periods, all three licensed nurses monitored made significant errors that could have compromised resident safety and treatment outcomes....
This delay in reporting had serious consequences for the 66-year-old resident, who has type 2 diabetes with diabetic neuropathy and chronic kidney disease....
However, this critical safety measure was not added to the resident's official care plan, leaving multiple staff members unaware of the new protocol....