Latest reports, citations, and penalties from CMS data
## Critical Medication Administration Failures The inspection revealed widespread medication management problems affecting eight residents....
In a separate incident involving a resident with leg wounds, the nurse practitioner again demonstrated poor hand hygiene practices....
The program was intended only for personal development and preparation for actual state-provided training, not as a substitute for required certification....
## Medication Monitoring Violations Discovered The May 2025 inspection documented serious deficiencies in the facility's pharmaceutical oversight system....
On January 9, inspectors observed a nurse performing complex respiratory care while failing to follow basic contamination prevention protocols....
These measures become particularly critical in congregate care settings where infectious diseases can spread rapidly among vulnerable populations....
This staffing model created significant gaps in care delivery, with periods where no cook, nurse, or CNA was available in certain areas of the facility....
During the inspection, Kitchen Aid staff and the Dietary Supervisor tested the Chicken Stir Fry with Vegetables being served to residents....
In the first case, a resident identified as R299 was admitted on October 4, 2024, with diabetes mellitus....
The resident was discharged home just five days later on January 13, 2025....
When surveillance documentation lapses, facilities lose critical visibility into emerging infection patterns and may miss opportunities for early intervention....
## Medication Management Failures The inspection uncovered significant concerns regarding medication administration and oversight at the facility....
This violation occurred despite facility policies mandating proper personal protective equipment during high-contact care situations....
Physician orders specifically required the IV access site to be flushed with 10 ml of normal saline solution before and after each medication administration....
Blood sugar levels above 350 mg/dL represent a medical emergency that can lead to diabetic ketoacidosis, a life-threatening condition....
The facility failed to properly monitor three residents on anticoagulant medications, which are blood thinners used to prevent clotting....
This violation relates to the facility's plan of correction from a previous survey that ended on July 12, 2024, with a completion deadline of August 11, 2024....
According to the inspection report, the facility's internal guidelines call for six CNAs per unit during day shifts when caring for a full census of residents....
The deficiency affected residents with terminal diagnoses including stroke and end-stage chronic obstructive pulmonary disease....
This designation is reserved for the most serious violations that could cause serious injury, harm, impairment, or death to residents....