Latest reports, citations, and penalties from CMS data
The April 2025 inspection also revealed problems with cold food service and improper dietary assessments affecting multiple residents....
The same resident experienced multiple documented skin injuries between March and April 2025, including abrasions to the forehead, knees, and scalp....
However, documentation shows the records were never provided....
The improper technique poses significant health risks, particularly for elderly nursing home residents who often have compromised immune systems....
For the second resident, an assessment with an ARD of May 5, 2025, remained incomplete at the time of the inspection on May 21, already seven days overdue....
Another resident reported being left in a wet incontinence pad for over two hours on the morning of April 23....
The April 2025 inspection revealed systemic breakdowns in fundamental healthcare practices that exposed vulnerable residents to preventable infections....
The Nurse Manager did follow proper hand hygiene protocols between steps but failed to don the required gown before beginning the procedure....
The inspection also revealed failures in basic hygiene protocols and active pest infestations in the facility's kitchen....
The director acknowledged responsibility for notifying residents or their representatives about scheduled care plan meetings....
These residents had not received timely evaluations or physician notifications as required by federal regulations....
When QAPI committees fail to function properly, patterns of deficiencies can persist unchecked, potentially affecting multiple aspects of resident care....
During the inspection, administrators identified Staff B as the interim Director of Nursing, a position they had assumed in February 2025....
The Director of Nursing (DON) acknowledged during an interview at 3:10 p.m....
The delay is particularly concerning given the resident's complex medical needs....
The resident walked directly onto a busy street with heavy traffic....
Beyond the sink misuse, inspectors documented extensive problems with food storage and quality control....
However, inspectors found the equipment remained in R15's bathroom even after the resident had been assisted to the dining room....
This systemic failure had devastating consequences for multiple residents who experienced preventable injuries....
Similarly, Resident #42 displayed symptoms starting April 26, progressing to a "congested cough and hoarse voice" by April 29....