Latest reports, citations, and penalties from CMS data
The wounds were serious enough to have their own entries in the resident's Comprehensive Care Plan, which had been in place since at least May 2023....
That is what the resident told inspectors three days after it happened....
An unstageable wound is one so covered in dead tissue or slough that its full depth cannot be determined....
Copies went to her, to the director of nursing, and to the office manager who handled scheduling....
Federal inspectors cited the facility under F0812, a food safety tag that covers the chemical sanitizers used on surfaces where food is prepared and served....
Nothing had ever been done about it....
The inspection, conducted July 10, 2024, was triggered by a complaint, not a routine survey....
Twenty minutes later, the man was dead....
Because the jeopardy period had already ended by the time inspectors completed their 2025 review, the citation was recorded as past noncompliance....
Then inspectors asked her about it directly....
The facility submitted a plan of correction....
The administrator and the director of nursing were in the room....
When a cook tested the machine on February 11, 2025, the test strip came back blank....
The inspection, completed March 12, 2025, was triggered by a complaint....
These were people who depended entirely on staff to manage their most basic bodily needs....
Federal inspectors reviewing records from a June 2024 inspection found that a resident identified in reports as R74 was admitted with fully intact cognition....
That phrase, "potential for actual harm," carries weight in nursing home oversight....
The facility set its own deadline....
That's what inspectors found in February at the 47-resident skilled nursing facility in Santa Rosa....
The seat was cracked and hanging sideways....