Latest reports, citations, and penalties from CMS data
The pharmacist's note specifically stated: "This resident continues on Trazadone 75mg qhs from 6/18/2023....
The resident, identified as Resident #5, had been admitted with multiple conditions including a spinal compression fracture, hypertension, and gout....
Federal inspectors determined that staff failed to follow established protocols during a transfer that resulted in resident injury....
This represents a fundamental breakdown in the facility's internal oversight mechanisms designed to identify, analyze, and resolve care quality issues....
Between monitoring checks, the resident successfully cut her right wrist with a microblade razor she had ordered online....
When investigators interviewed Resident 1, they found her call light cord wrapped around the bed frame and completely out of reach....
This delegation of responsibility created a dangerous gap in medical communication....
The resident was subsequently hospitalized and diagnosed with cerebral infarction, hemiparesis affecting the right dominant side, and slurred speech....
The facility's physician had specifically ordered a 16 French Foley catheter with a 10cc balloon for the resident's urinary retention condition....
One of the most concerning incidents involved insulin administration for a diabetic resident....
During the inspection, the family member stated they were "tired of buying new clothing every week" for the resident....
Activities of daily living include essential tasks such as bathing, dressing, transferring from bed to wheelchair, and toileting....
The resident, who has been receiving dialysis for many years due to end-stage renal disease, reported concerning gaps in post-treatment monitoring....
In nursing station refrigerators, inspectors discovered numerous unlabeled and undated food items that posed potential health risks to residents....
On October 7, 2024, the resident's blood sugar reached 465 mg/dL at 3:14 p.m., followed by readings of 453 mg/dL at both 5:46 p.m....
Inspectors found that none of the six residents reviewed had proper documentation supporting their antibiotic treatments....
When these committees fail to function effectively, it creates a cascade of problems that can directly impact resident care and safety....
When inspectors arrived on March 20, they discovered the tube site had **thick, mucous drainage with dried dark red discharge** around it....
The investigation focused on three specific cases where residents experienced uncontrolled pain due to medication administration failures....
During the March 11-13 inspection period, surveyors documented persistent contamination despite multiple visits....