Latest reports, citations, and penalties from CMS data
## Critical Safety System Failures The April 2025 inspection revealed a cascade of security failures that put vulnerable residents at serious risk....
The incident occurred during routine care around 5:00 AM when the staff members entered the resident's room to change bedding and provide personal care....
This oversight directly impacts residents' eligibility for government benefits and their financial security....
According to the inspection report, the resident's July 2024 medication records showed **no documented episodes of insomnia throughout the entire month**....
Most concerning were two white, round tablets and one pink tablet that were completely unmarked and unidentifiable....
The violations involved both timing errors and failure to monitor vital signs before administering potentially harmful medications....
Federal regulations require nursing homes to maintain effective QAPI programs to ensure resident safety and regulatory compliance....
On December 13, 2024, at approximately 2:30 PM, Employee 14 manually lifted Resident 57 under both arms during a wheelchair transfer....
Security footage revealed that CNA #1 immediately began striking the wheelchair-bound resident with closed fists to his face, head, and chest....
## Regulatory Compliance Failures The inspection revealed violations of **28 Pa....
This decision directly contradicted the facility's own written policies requiring immediate suspension of staff members facing abuse allegations....
**Unlabeled and Contaminated Equipment** Inspectors observed widespread problems with respiratory equipment labeling and storage throughout the facility....
The incident involved the spouse of one resident physically hitting another resident who was reaching up toward her while being transported in his wheelchair....
The investigation revealed that **30 of 45 residents diagnosed with dysphagia required updates to their care plan interventions** for feeding assistance....
However, the resident's TAR showed missing initials for treatments that should have been administered on May 21, 2024, at 9:00 AM and 1:00 PM....
Inspectors discovered the policy had not been reviewed or updated since October 2022, leaving it nearly two years out of date at the time of the survey....
Over the course of just one afternoon, inspectors documented three separate incidents where nursing staff failed to follow proper sanitization procedures....
## Critical Medication Management Failures Put Residents at Risk The most serious violation documented at the 1640 N....
Extended periods of inactivity and social isolation can lead to accelerated cognitive decline, increased anxiety, and a diminished sense of purpose....
The first fall occurred on September 5, 2024, when a Certified Nurse Aide (CNA) assisted the resident to the bathroom and left her unattended on the toilet....