Latest reports, citations, and penalties from CMS data
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....
The medication error occurred at Ellicott City Healthcare Center on November 4 while federal inspectors were conducting a complaint investigation....
The incident occurred on September 5, 2025, when Resident #2 sustained what would later be confirmed as a fractured hip....
The October 14 incident was reported by a charge nurse, who documented that the victim was moved away from the perpetrator and placed on 15-minute monitoring....
The resident, identified as R5 in inspection records, sustained a silver dollar-sized bruise on her shin and ankle during a transfer on October 21....
The bedpan was typically stored in the bathroom when not in use....
V12, hired as the full-time Social Service Director on July 19, 2021, had completed only high school education according to her employment record....
V12, the facility's Social Service Director since July 2021, has completed only four years of high school education according to her employment record....
At 8:52 p.m., Pharmacy 1 delivered seven vials of amphotericin B 50 mg along with dextrose solution to RN 3....
The amphotericin B should have been mixed in 3,500 ml of fluid and infused over four to six hours....
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....
Federal inspectors reviewed surveillance footage and interviewed staff after receiving a complaint about the facility's care....
The incident at Avir at Magnolia involved multiple staff members restraining Resident #2 while attempting to clean him after a bowel movement....