Latest reports, citations, and penalties from CMS data
The nurse administered two different eye drops at 8:26 AM and 8:27 AM without the required waiting period....
The discovery prompted immediate action to protect residents' health and safety....
## **Critical Reporting Protocol Failures** The inspection revealed significant breakdowns in the facility's abuse reporting system....
The inspection found residents who had consented to receive pneumonia vaccines but never received them....
The facility, located at 501 W Austin Street, also faced citations for inadequate registered nurse coverage on weekends....
## Medical Necessity of Adaptive Equipment The prescribed No Spill 360 Grip and Sip cup serves critical medical purposes for residents with cerebral palsy....
Medical orders were issued to treat the injuries with normal saline and antibiotic ointment....
On August 23, 2024, staff discovered an open area on the resident's buttocks during routine skin observations....
## Critical Monitoring Gaps Discovered During a March 2025 inspection, surveyors identified multiple failures in the facility's skin care program....
In response, facility leadership submitted a Plan of Correction (PoC) on February 14, 2025, promising comprehensive reforms to address these critical issues....
The facility failed to complete a bed hold arrangement, which would have preserved the resident's place at the nursing home during the hospital stay....
Hospital records showed the patient had been prescribed Seroquel, a powerful antipsychotic medication, to be taken at 50 milligrams once daily at bedtime....
This regulation serves as a cornerstone of patient safety in long-term care settings....
Medical records show the resident missed one feeding on January 22, three on January 23, two on January 24, and one on January 25....
The violation affected a small number of residents at the 99-bed skilled nursing facility....
The resident lost 9 pounds in January alone, representing a 7.6% weight loss, followed by an additional 15 pounds the following month....
Multiple residents reported waiting 20 to 30 minutes for assistance, with some calls going completely unanswered....
The resident explained that her hands were numb due to neuropathy, making her unable to remove the hearing aids independently....
These lab values indicated the resident faced immediate medical risks....
The clothes were described as "stiff" and "rigid" with a musty odor that made them difficult to handle....