Latest reports, citations, and penalties from CMS data
On July 13, 2024, at 5:24 a.m., the resident complained of pain extending from his groin down to his thigh....
The facility's own assessment indicated side rails were not recommended for this resident, yet staff continued using them as restraints....
These oversights can lead to outbreaks of foodborne pathogens such as Salmonella, E....
Inspectors documented soiled surfaces, contaminated equipment, and improper food storage that violated fundamental food safety protocols....
The contamination was so severe that it extended into the dining hall where residents were actively eating their lunch....
Inspectors found that licensed nurses repeatedly failed to rotate injection sites for residents receiving insulin therapy, a fundamental safety requirement....
The violations centered on expired medications remaining in active use and improperly labeled drugs throughout the facility's medication distribution system....
Federal surveyors identified immediate jeopardy conditions on March 3, 2025, with the violation dating back to February 26, 2025....
The resident reported waking up one night to see a mouse near the bathroom entrance and informing staff about the problem....
This represents a fundamental breakdown in the facility's internal monitoring and improvement processes that are designed to ensure quality care....
On January 28, 2025, at approximately 5:30 a.m., Licensed Practical Nurse Staff B changed the resident's catheter per physician orders....
These small flying insects can carry bacteria and other pathogens on their bodies, potentially transferring contaminants between surfaces and food sources....
The incident occurred on August 18, 2024, at approximately 8:00 a.m., but was not reported to the California Department of Public Health until 11:55 p.m....
When surveyors returned the next day, the resident still lacked a call light system in his room....
This cross-contamination scenario represents a fundamental breach of infection control protocols....
Inspectors found systemic failures in following these protocols for residents requiring specialized protection....
The physician had ordered that oxygen levels be maintained at 94% or higher, with specific instructions to increase oxygen delivery if levels dropped....
The IP's training transcript revealed completion of only 15 out of the required training modules, with one course still outstanding....
The incident involved an Evolution wheelchair, a specialty mobility device that requires specific training for safe operation....
However, inspectors found no physician's order authorizing the transfer in the medical record....