Latest reports, citations, and penalties from CMS data
According to the Nursing Home Administrator, proper staffing levels should include **one cook and three dietary aides for each shift**....
According to the inspection report, staff used a "shower or toilet" sling rather than the standard transfer sling required for bed transfers....
The resident remained on a regular diet with no nutritional modifications despite consuming only **26-75% of meals**....
However, the medication was never transcribed into the facility's medication administration system and was therefore never given to the resident....
In June 2024, eight of 23 treatment opportunities for the heel wound were not completed, and six of 11 opportunities for the knee wound were missed....
According to treatment records, when the resident's catheter became blocked on February 1, 2025, nursing staff replaced it—but used the wrong equipment....
These protocols are specifically designed to prevent the transmission of multi-drug resistant organisms between vulnerable residents....
The facility's treatment systems failed at multiple levels, creating serious risks for vulnerable residents requiring specialized wound management....
The one-star staffing designation reflects more than just numbers on a spreadsheet....
The bag remained accessible to residents with cognitive impairments who regularly wandered the hallway....
When two residents approached the medication cart, the nurse handed each a cup of medications from the top drawer without checking the electronic record....
Emergency medical personnel arrived to find no resuscitation efforts had been attempted by facility staff....
Healthcare facilities implement enhanced barrier precautions because residents with invasive devices face significantly elevated infection risks....
The failure to follow these protocols represents a breakdown in resident safety systems designed to protect vulnerable individuals....
Inspectors identified systemic failures in how staff assessed fall risks and communicated safety measures....
The nurse subsequently admitted to borrowing the Lasix from another nurse - medication that belonged to a different resident entirely....
The facility's medical provider ordered a venous doppler study, a diagnostic ultrasound procedure used to detect blood clots in veins....
The electronic medication administration records from June 4-17 revealed an extensive pattern of medication refusals....
## Inadequate Pain Management Protocols Inspectors identified concerning gaps in pain management for a resident experiencing chronic, severe pain....
The incident occurred when a Certified Nursing Assistant (CNA) was turning and repositioning the resident, who grabbed onto the facility's bed remote control....