Latest reports, citations, and penalties from CMS data
The Minimum Data Set nurse who conducted the assessment acknowledged the error during interviews with inspectors on May 4....
The 43-bed Tabor Manor Care Center has struggled with a failing call light system since mid-December, federal inspectors found during a February visit....
Her medical conditions include depression, muscle wasting, and being unsteady on her feet....
When the family member arrived at the facility and walked past staff in the hallway, they found the resident needed to be changed and required a new gown....
The physician ordered 20 repetitions, three sets each, five days per week....
When the nursing assistant tried again to put the sock on, the resident screamed and pulled her left leg away, telling the assistant not to touch her leg....
The aide changed gloves twice during the procedure without washing her hands, creating potential for cross-contamination....
The Activity Director reported to the Director of Nursing that a student had been touched inappropriately, with another student witnessing the incident....
The nurse never changed gloves....
Instead, they found metformin, a diabetes medication....
The violations centered on two residents with serious medical conditions requiring enhanced barrier precautions....
The facility's own policy requires staff to answer call lights immediately, but no longer than five minutes....
The 83-year-old resident arrived at the facility on a Tuesday with a drain tube inserted in her abdomen following surgery for a perforated duodenal ulcer....
The resident, identified as R #42, was prescribed clopidogrel 75 mg daily following a hospital stay in October 2024....
Certified Nursing Assistant 3 told inspectors she first noticed the pressure injury during that week....
But her admission record showed diagnoses of only bipolar disorder and dementia....
The family member told federal inspectors they had to cut the resident's nails during every visit to prevent injury....
Federal inspectors found three residents with cognitive impairments sharing the water-covered bathroom, all at high risk for falls....
The resident, identified in inspection records as R1, had scored eight out of 15 on a cognitive assessment in May, indicating moderate impairment....
Staff searched the building before finding her at the gas station across the street....