Latest reports, citations, and penalties from CMS data
The inspection, conducted on August 12, 2025, caught the problem during a routine review of one of two medication carts at the facility....
The resident, identified in inspection records only as R5, uses an indwelling urinary catheter because of a neuromuscular dysfunction of his bladder....
Resident R1, a man with chronic kidney disease, urinary retention, and a freshly placed urinary catheter, was alone....
What happened next became the subject of a complaint, a facility investigation, and ultimately a federal inspection citation....
The facility opened it before he ever saw it....
That was not the first time inspectors had seen the insects that week....
That was not the worst thing inspectors found that week....
That detail came from an interview inspectors conducted on August 12, at 10:22 in the morning....
Somerset Healthcare & Rehabilitation Center was cited in October 2024 for failing to provide comprehensive care plans for its residents....
Inspectors arrived on August 12 and spent nearly two hours observing the first floor nursing unit....
It was not the first time inspectors had found this....
A nurse aide who saw it described the result plainly....
The facility never notified the California Department of Public Health about the outbreak, according to a complaint inspection completed August 12, 2025....
The form listed staffing levels that were two days old....
The resident, identified in the inspection report only as R1, had a tracheostomy....
The finding, documented in a complaint inspection completed February 28, 2025, placed Capstone at the most serious level of federal deficiency....
The resident, identified in inspection records as R74, had been referred for a restorative nursing program after completing therapy....
The fall happened on July 25, 2025, at Maples Benzie County Medical Care....
R3 was admitted on July 30, 2025....
The resident, identified in inspection records as R4, was admitted to Greendale Park Nursing and Rehab on December 10, 2024....