Latest reports, citations, and penalties from CMS data
Resident 174 was admitted on October 29, 2023, but didn't receive wound care orders until October 31 â 48 hours later....
The licensed vocational nurse working that shift acknowledged the problems immediately....
The resident required a coude foley catheter â flexible tubing with a bent tip designed to navigate around obstructions like an enlarged prostate....
Instead, nurses administered the drug repeatedly when the resident's pressure exceeded that threshold, potentially worsening their condition....
The patient had suffered a suspected overdose on March 28....
The resident had been admitted earlier this year and was found to have "no capacity to understand and make decisions" during an August 10 examination....
The 51-bed facility's breakdown began after the resident returned from a nephrology appointment on January 20....
The facility's own policy required nurses to complete informed consent forms before starting any new psychoactive medications....
The contamination problems at California Post-Acute Care extended beyond misplaced trash....
Resident #2 wandered into Resident #4's room on August 25, picked up his lunch tray, removed clothing from his bed, then laid down on it....
Video surveillance captured the neglect in real time....
The resident, identified as Resident #25, was found holding the white call cord and continuously pushing the button....
The incident at Carrara involved a resident who required regular dialysis treatments....
The September 2nd incident escalated when the victim immediately retaliated with a punch to his attacker's upper chest....
The April 12 incident exposed multiple safety failures at the facility....
After Christmas, everything changed....
The facility's medical director had specifically ordered the leg anchor as "best practice" to protect the resident's urethra....
The incident involved a resident whose oxygen levels had dropped to dangerous levels, triggering alarm signals on monitoring equipment....
The facility's written policy, titled "Residents Rights," acknowledges federal and state privacy guarantees....
Federal inspectors discovered the security failures at Oasis at The Conch Republic Nursing and Rehab during a September complaint investigation....