Latest reports, citations, and penalties from CMS data
The violation centered on Resident #1, a male patient with severe intellectual disabilities, cerebral ischemia, muscle wasting and a history of falling....
Federal inspectors found that Citrus Grove Post Acute failed to ensure a safe discharge for the resident on December 17, 2025....
The resident had been alert and oriented when she was admitted to Imperial Healthcare Center on August 11....
"[Resident 2] is not calm," Certified Nurse's Aide 1 told inspectors....
She said there was "not a negative outcome because she had the verbal order." But the facility's own policy contradicts that approach....
Federal inspectors who visited the facility on December 31 found that nursing staff weren't following required procedures for tracking controlled medications....
Resident 2's physician orders were clear and specific....
The incident unfolded when CNA 1 discovered Resident 1 outside at the front of the facility....
Resident 1 at Sunnyview Care Center developed moisture-associated skin damage on his sacrococcyx and groin area....
Federal inspectors discovered the unreported incident during a complaint investigation completed on December 31....
The supplements, discovered during a December 30 inspection, had expired on September 10, 2025....
But inspectors found a gap between written policy and actual practice....
Resident #1 first disappeared on November 17, 2025....
Federal inspectors observed the violation firsthand when they watched the nursing assistant enter the room improperly equipped....
Three days later, the resident fell....
Staff found her on the floor with no visible injuries during their initial assessment....
Federal inspectors found the violation during a complaint investigation on January 2....
Federal inspectors found the breakdown in communication at Chestnut Ridge Post Acute LLC during a complaint investigation completed January 2....
The medications were specifically ordered to manage the resident's COPD....
Federal inspectors found the social worker, identified only as SW 1, had no idea where most of the forms were located during interviews on January 2nd....