Latest reports, citations, and penalties from CMS data
When surveyors requested monthly infection surveillance reports for 2025, nursing staff initially could not provide the documentation....
The inspection resulted in citations under reference WAC 388-97-1100(1), which governs nursing home operational standards and resident care requirements....
Inspectors found that residents with diagnosed mental health conditions were not receiving the specialized care outlined in their treatment plans....
However, this admission highlighted a dangerous gap between knowledge and practice that could have exposed other residents to the influenza virus....
The violations occurred across several areas of the facility's food service operations, including storage, temperature monitoring, and handling procedures....
"RN 2 stated there were multiple instances that the sites of insulin administration of insulin were not rotated," according to the inspection report....
For patients with atrial fibrillation, blood thinners are essential medications that prevent potentially fatal blood clots from forming....
When staff finally identified the penile split in April 2024, they failed to measure it, update his care plan, or ensure immediate physician notification....
Despite receiving detailed referral information from a local hospital, the facility failed to take appropriate action to ensure the resident's safety....
Medical records showed the resident was unable to move his leg, and his knee and foot appeared severely swollen....
A housekeeper present in the room was cleaning and did not witness the fall....
Resident B1, who has diabetes and joint disease, told inspectors during the July 2 visit: **"Staff sometimes don't give me a shower....
The inspection found that The Center at Advocate had been operating without a certified infection preventionist since April 2024....
During this 11-day period without proper monitoring, the resident developed an unstageable pressure ulcer on her sacrum that became necrotic....
Medical records show the resident was prescribed Oxycodone 5 mg every 12 hours as needed for pain on March 1 at 2:00 PM....
During the initial tour on March 10, investigators found an unlocked cart on the 300 hallway containing five opened, undated insulin pens....
According to the inspection report, the first incident occurred on December 25, 2024, when the resident's wife arrived to take him home from the facility....
Pneumonia poses a particularly serious threat to nursing home residents, who are among the most vulnerable populations for severe respiratory infections....
The citation followed documented incidents involving a resident who managed to leave the facility on multiple occasions due to systemic security breakdowns....
The case reveals a cascade of clinical failures that allowed a minor injury to worsen significantly....