Latest reports, citations, and penalties from CMS data
The resident had a 7.5 size tracheostomy tube in place, but facility records incorrectly indicated it was a 6.5 size....
Any changes in a resident's condition or oxygen needs should be immediately reported to the attending physician for potential order modifications....
Normal oxygen saturation ranges from 96 to 100 percent....
On August 13, 2024, inspectors observed a registered nurse hanging IV fluids for the resident without wearing the required protective gown....
Within days of admission, staff completed a PHQ-9 depression screening that revealed a score of 17 - indicating moderately severe depression symptoms....
The dirty laundry area contained a large bin with an askew lid that was full of dirty laundry, some of which was unbagged....
A colleague who witnessed the incident reported that the CNA used the resident's personal beard shaver to perform the grooming....
## Medication Storage and Safety Failures Federal inspectors documented serious medication management issues throughout the facility....
The facility holds monthly QAPI meetings with quarterly participation from the medical director and pharmacist, as required by regulations....
After removing the old dressing and cleaning fecal matter from the resident's anal area, the nurse changed gloves but failed to sanitize hands between steps....
The violation came to light when another nursing assistant reported seeing the post on the offending employee's TikTok account....
The nurse had set the IV flow regulator to 200 ml/hr instead of the prescribed 135 ml/hr - a significant deviation that could cause harmful side effects....
The review process evaluated insulin administration protocols, physician orders, and compliance with prescribed treatment regimens....
This citation represents a significant finding where the facility's practices directly impacted resident safety and wellbeing....
This safety protocol was clearly outlined on the CNA Assignment Sheet and in the resident's care plan dated April 28, 2023....
The Memory Care Coordinator reported working despite feeling ill, having "spent the weekend in bed sick" with chills and diarrhea....
Federal regulators classified the violation as affecting "few" residents but requiring urgent corrective action....
## Poor Appetite and Inadequate Nutrition Monitoring Daily intake records revealed consistently low food consumption....
Despite physician orders requiring **"total supervision and assistance with meals,"** staff repeatedly left the resident to eat alone....
He expressed concern about losing progress he had made during his initial therapy sessions....