Latest reports, citations, and penalties from CMS data
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....
Despite these clear medical orders, the facility's systems failed to ensure consistent delivery of this essential equipment....
This fundamental breach of medication management protocols creates significant health risks....
The violations affected up to 43 residents who regularly ate in the facility's dining areas....
The bacon registered even lower at **77.5°F**, while toast arrived cold at **74.8°F** with unmelted butter still sitting on top....
The kitchen failed to maintain basic food labeling and dating protocols, with multiple items stored without proper identification or expiration dates....
The meatloaf registered at 135°F for regular texture and 127°F for pureed versions, while the spinach au gratin measured only 126°F....
Federal and state regulations mandate that nursing homes maintain an RN on duty for at least eight consecutive hours daily, seven days a week....