Latest reports, citations, and penalties from CMS data
When maintenance staff attempted cleaning with dish soap and an aqua-colored solution, inspectors noted these products were inadequate for proper sanitization....
## Prolonged Neglect of Basic Hygiene Needs The most troubling finding involved a paraplegic resident who required complete assistance with incontinence care....
Despite CPR efforts and emergency transport to the hospital, the resident experienced severe brain damage from oxygen deprivation....
Records showed the resident's referral documentation from her previous facility explicitly noted a suicide attempt just weeks before her transfer....
The 180-year-old resident, admitted on January 29, 2025 with pneumonia and sepsis, had an indwelling urinary catheter placed for benign prostatic hyperplasia....
When mobility requirements change due to illness, recovery, or decline, accurate documentation becomes essential for preventing falls....
That citation specifically addressed the facility's failure to have medications available for administration....
Despite these documented vulnerabilities and cognitive limitations, the facility's window security measures proved inadequate to prevent his escape....
The incident occurred when the newly admitted resident attempted to take a cigarette from another resident on the facility's smoking patio....
Despite the resident taking this antibiotic continuously for over a year, **no medication review records existed for January through March 2025**....
For residents with PTSD, exposure to specific triggers can precipitate severe anxiety, flashbacks, or dissociative episodes....
This represents a fundamental breakdown in the facility's ability to identify and address care quality issues before they impact residents....
Additionally, no Change of Condition form was completed to document the wound's advancement from MASD to a Stage 2 pressure injury....
PICC lines are sophisticated medical devices—thin, flexible tubes inserted into an upper arm vein and threaded to a large vein near the heart....
The resident experienced episodes where he believed he was still in combat or that the U.S....
The resident was discovered on the facility's loading dock, standing on a hydraulic lift raised 81 inches from the pavement below....
Despite facility policy requiring immediate nursing assessment after any fall, the aide failed to notify nursing staff or supervisors about the incident....
Medical records revealed nursing staff administered the medication on multiple occasions when blood pressure readings were well above these thresholds....
Instead, staff served the meal on a single plate with all items mixed together....
However, documentation revealed this critical recommendation was never implemented....