Latest reports, citations, and penalties from CMS data
Stage 4 pressure ulcers represent the most severe category of pressure injuries, involving full thickness tissue loss with exposed bone, tendon, or muscle....
The facility's emergency food calculations revealed significant gaps in planning....
The violations occurred during both 2023 and 2024 reporting periods....
The resident's Medicare assessment showed a BIMS cognitive score of 14, indicating full mental capacity to understand and consent to medical treatments....
## Paint Brush Food Preparation Violations The most egregious violation involved kitchen staff using paint brushes to prepare food for residents....
This comparison revealed the significant dosing discrepancy that facility staff had missed during the admission process....
This violation represents a continuing pattern of deficiencies, with previous citations issued in November 2018, November 2019, and January 2024....
Inspectors found that multiple employees had been hired and worked for months without receiving mandatory food safety education or competency assessments....
The facility's own policy, revised in November 2023, clearly outlined these requirements....
When these medications are given hours late, several dangerous scenarios can occur....
Federal regulations require sanitizing solutions to maintain specific chemical concentrations to effectively kill dangerous pathogens....
This admission represents a fundamental breakdown in resident protection systems....
A resident with severe cognitive impairment and dementia was taking multiple medications that the facility's pharmacist identified as problematic....
The medications were labeled with the resident's name but came from an outside pharmacy, violating facility policies....
The plans required Licensed Practical Nurses to receive education about checking carts for expired medications three times per week....
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....
During the inspection, federal surveyors observed the injury measured approximately 3.8 centimeters by 2.5 centimeters under the resident's left eye....
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....