Latest reports, citations, and penalties from CMS data
His doctor also ordered nurses to verify the oxygen humidification bottle contains adequate distilled water at least every shift....
She emphasized that no clinical discharge summary was provided with the transfer....
Resident 5 swallowed four medications meant for someone else at 9:00 AM on October 17, according to inspection records....
The resident's spouse discovered the problem after the regular meal period had ended....
Staff B, a registered nurse at Southeast Iowa Regional Medical - Klein Center, found the resident on the bathroom floor....
The resident's medical record, known as a Kardex, clearly indicated she needed two-person assistance for all transfers using mechanical equipment....
The problems began on August 5 when staff discovered a stage 2 pressure injury in the resident's gluteal cleft....
The October 9 accident at The Meadows left the resident bleeding profusely from their forehead while still attached to the Hoyer lift sling....
The November incident at Buena Park Nursing Center exposed a basic breakdown in patient safety protocols....
Staff also failed to check her blood pressure that day, leaving blank entries on her medication administration record....
The resident had undergone a breast biopsy that left her with a surgical incision....
on January 18, 2024, after choking in their room....
The bedpan was typically stored in the bathroom when not in use....
At 8:52 p.m., Pharmacy 1 delivered seven vials of amphotericin B 50 mg along with dextrose solution to RN 3....
According to witness statements obtained by inspectors, the staff raised the bed to hip level and used physical restraint when the resident became combative....
The resident at AVIR at Lancaster hadn't received monthly statements since July 2025, federal inspectors found during a November complaint investigation....
The Director of Nursing told inspectors on November 5 that the facility only made phone calls to let families know their loved ones were being moved....
Her certification expired while she continued working on the floor caring for residents....
AS 1 had been supervising Resident 1 in the Activity Room when her shift ended at 5:00 PM....
The resident had slipped out of Sunset Home's memory care unit early in the morning, triggering a Code Purple missing resident alert....