Latest reports, citations, and penalties from CMS data
However, the resident's TAR showed missing initials for treatments that should have been administered on May 21, 2024, at 9:00 AM and 1:00 PM....
Inspectors discovered the policy had not been reviewed or updated since October 2022, leaving it nearly two years out of date at the time of the survey....
Over the course of just one afternoon, inspectors documented three separate incidents where nursing staff failed to follow proper sanitization procedures....
## Critical Medication Management Failures Put Residents at Risk The most serious violation documented at the 1640 N....
Extended periods of inactivity and social isolation can lead to accelerated cognitive decline, increased anxiety, and a diminished sense of purpose....
The first fall occurred on September 5, 2024, when a Certified Nurse Aide (CNA) assisted the resident to the bathroom and left her unattended on the toilet....
The QAPI committee serves as the central hub for identifying problems, developing solutions, and ensuring ongoing compliance with health and safety standards....
**Resident #529** faced the most severe consequences from these monitoring failures....
The nurse was observed removing contaminated gloves and immediately putting on new gloves without sanitizing her hands between the glove changes....
The consequences of inadequate supervision can be catastrophic....
The incident revealed multiple breakdowns in communication and medical care that put the resident at significant risk....
When investigators returned nearly an hour later, the temperature remained at the same unsafe level....
Licensed Vocational Nurse 1 (LVN 1) completed the transfer form but failed to document whether or when the resident's emergency contact was notified....
Care conferences are mandatory meetings where healthcare teams, residents, and families discuss treatment plans, goals, and care needs....
The incidents involved taking residents' walkers, pushing residents, punching, spitting, and **knocking pictures off walls to throw them**....
## Medication Management Failures The facility faced significant citations related to proper medication administration and monitoring....
Inspectors observed three separate incidents where nursing staff provided direct care to residents without proper hand sanitization....
Documentation shows the medication was administered inappropriately on March 3, March 4, March 15, March 19, May 9, and May 11, 2025....
In one case, a low air loss mattress designed to prevent pressure sores was set at 550 pounds for a resident who weighed only 138 pounds....
According to the inspection narrative, the facility initiated a "Code W" elopement protocol and began searching the building and surrounding perimeter....