Latest reports, citations, and penalties from CMS data
The violations affected staff across multiple departments, including certified nursing aides, housekeeping, and maintenance personnel....
On October 3, 2024, nursing staff discovered maggots in the resident's right heel wound during a routine dressing change....
Three of these individuals had been employed in nursing roles since 2021, while two others had worked without proper licensing since 2023....
Despite this nurse providing a written statement about what she observed, facility administration conducted no thorough investigation....
The inspection revealed systemic breakdowns in basic safety protocols affecting multiple areas of resident care....
The violations involved improper handling of medical equipment and inadequate use of protective equipment when caring for vulnerable residents....
The most recent documented assault had occurred just weeks before the transfer....
Water at 127 degrees Fahrenheit can cause first-degree burns in just one minute of exposure....
Long, untreated toenails in elderly residents create significant health risks beyond discomfort....
By May 2025, the 58-year-old resident reported she could no longer see faces, read books, or even see her food during meals....
On February 4, 2025, the facility's administrator received a report that CNA #1 had been physically rough with a resident during a transfer attempt....
However, **no evidence existed that the serum level was ever drawn**, and neither the physician nor nurse practitioner followed up on the missing results....
The meal remained at room temperature for nearly three hours....
The facility demonstrated multiple failures in outbreak management....
The wound was first documented on July 3, 2024, but **staff never measured the wound** and failed to track its progression over the following month....
The physician ordered a Depakote serum level test to be collected on February 25, 2025, following the pharmacist's recommendation....
For patients with chronic lung conditions, dry oxygen can cause airway irritation, increased mucus production, and breathing difficulties....
The facility's Infection Preventionist confirmed during an interview that the resident had MRSA in his leg wounds and was receiving antibiotic treatment....
The resident, who had dementia and exhibited physical behaviors, rejection of care, and wandering, began hospice services on January 17, 2025....
Medical records showed the resident's weight began declining sharply in April, with an 8-pound loss in just one month between April and May....