Latest reports, citations, and penalties from CMS data
Some staff reported that previous administrators would purchase food to pacify the aggressive resident rather than addressing the underlying behavioral issues....
This delay in medical notification prevented timely interventions that could prevent minor issues from escalating into serious medical emergencies....
The resident, identified as R8, was discovered on December 22, 2024, in a compromised position after attempting to get out of bed....
The violations centered on two critical incidents: an allegation of staff-to-resident physical abuse and a resident elopement from the facility....
This disruption affected at least four residents who required essential blood work to monitor medication levels and health conditions....
## Critical Gaps in Medical Device Management State inspectors identified concerning lapses in care for residents requiring specialized medical equipment....
During the inspection, **surveyors observed the resident raising her buttocks and waist from her bed with no alarm sounding**....
The facility's response to this incident initially created additional compliance issues....
This type of mold exposure poses serious health risks, particularly for elderly residents with compromised immune systems....
A licensed practical nurse properly performed most aspects of the glucose testing procedure, including hand hygiene, glove use, and finger cleaning....
On the Oceanview unit, the most severe temperature violations occurred when the test tray was received 26 minutes after the food cart arrived....
The insulin pen was found stored in a medication cart with a label showing it had expired according to manufacturer guidelines....
One resident experiencing chronic leg pain rated their discomfort at 7-8 out of 10 but received only ineffective Tylenol instead of prescribed Tramadol....
When residents needed specialized mental health care, the facility's social worker was responsible for making outside referrals....
Despite the fall and impact with the wheelchair, the incident was not reported to nursing staff or supervisors....
The carts contained prescription medications for resident treatments and remained accessible without any staff supervision....
The resident had scored a **3 out of 15** on the Brief Interview for Mental Status assessment, indicating severe cognitive impairment....
During an interview, R3 described being placed on a bedpan by staff and then waiting **four hours** before anyone responded to her call light for removal....
The inspection revealed multiple instances where beef was served for up to four consecutive meals, and poultry for three consecutive meals....
On March 9, 2025, R103 attacked another severely cognitively impaired resident (R83) three separate times within a 45-minute period....