Latest reports, citations, and penalties from CMS data
The resident had a Brief Interview for Mental Status score of 6 out of 15, indicating severe cognitive impairment....
Federal regulators found that facility staff failed to follow basic nursing protocols for uncircumcised males....
Federal inspectors classified the violations as immediate jeopardy, the most severe category indicating imminent danger to residents....
The incident occurred despite the resident's allergy being clearly documented across multiple medical records, care plans, and dietary profiles....
## Medical Significance of Wheelchair Safety for Amputees Residents with lower limb amputations face significantly higher fall risks when using wheelchairs....
A restorative nursing assistant observed on July 30, 2024, was unable to explain why the sock and bandage combination had been placed on the resident's hand....
**Resident 10**, who receives hemodialysis three times weekly through a chest wall tunneled catheter, lacked proper infection control precautions....
According to the inspection report, **Resident 112** required the medication for overactive bladder and urinary incontinence....
This condition causes rapid kidney function deterioration over weeks to months....
## Medical Timeline Reveals Rapid Deterioration The resident's medical records show a rapid progression from a minor wound to amputation....
Inspectors observed two nursing assistants who did not follow manufacturer guidelines for the specialized equipment....
According to inspection records, Resident 1 had been diagnosed with **schizoaffective disorder, generalized anxiety disorder, and bipolar disorder**....
According to inspection records, insulin was administered in the left lower quadrant of the abdomen on February 2, 3, 8, and 15, with minimal variation....
The facility failed to offer or administer Prevnar 20, a pneumonia vaccine specifically recommended for adults 65 and older....
Staff interviews revealed systemic problems with the facility's bathing program that left vulnerable residents without essential hygiene care....
Both residents had **severely impaired cognition** with Brief Interview of Mental Status (BIMS) scores of 7, indicating significant cognitive deficits....
When the case manager informed him of the resident's refusal to see him, FM 4 became agitated and walked toward her room stating "that is a lie!...
The resident, identified as CR #1, was admitted with multiple serious conditions including heart failure, diabetes, morbid obesity, and atrial fibrillation....
## Food Storage Violations Put Residents at Risk The inspection revealed several concerning food safety practices in the facility's kitchen....
Federal inspectors found the COTA was still scheduled to work as late as the day before the inspection, despite having an expired license....