Latest reports, citations, and penalties from CMS data
The resident, identified in the report as R2, was last observed by medication staff at approximately 3:00 PM....
These residents required enhanced barrier precautions due to their indwelling medical devices, which significantly increase infection risk....
The bag contained no labeling indicating the medication type, opening date, expiration date, or intended recipient....
## Pressure Injury Care Falls Short of Standards Inspectors identified systemic failures in pressure injury prevention and treatment affecting six residents....
Despite this knowledge, a certified nursing assistant left him unsupervised on the patio during lunch service....
The resident had recently been hospitalized on a psychiatric hold for threatening to kill staff and blow up a hospital....
Federal regulations mandate that facilities investigate all injuries of unknown origin to rule out potential abuse, neglect, or mistreatment....
On March 10, 2025, the aggressive resident pinched another resident's leg during a witnessed altercation....
The MCU houses residents with dementia and cognitive impairments who require specialized supervision to prevent wandering and potential harm....
However, interviews with nursing staff revealed that many were unaware of the unauthorized medications....
Licensed Practical Nurse #10, who was caring for the resident during the day shift, contacted the facility's nurse practitioner about the elevated heart rate....
Rather than pursuing alternative solutions or escalating the communication breakdown between providers, facility staff allowed the situation to continue....
This cross-contamination issue could have impacted 128 out of 133 residents who consume food orally....
The incident involved Resident 48, who was readmitted to the facility with complete paraplegia and essential hypertension and was receiving hospice care....
Proper assessment should include identifying environmental factors, interpersonal situations, or sensory experiences that may precipitate episodes....
The problem became so persistent that residents filed formal grievances in December 2024 and again in February 2025....
One CNA, employed since November 2022, had not received the required annual abuse training during the 12 months prior to the inspection....
The resident in question possessed baby dolls with hard plastic heads, which became weapons during aggressive episodes....
The medical director, identified as MD N, confirmed the pattern of administrative absence during her interview with inspectors....
This violated the fundamental protection that ensures residents cannot be arbitrarily removed from their homes without due process....