Latest reports, citations, and penalties from CMS data
The chain of events began when one nursing assistant witnessed another yelling at a pediatric resident....
The facility's own policy required reporting suspected abuse to state agencies within 24 hours....
The medication aide, identified as MA B in federal inspection records, had been hired at Laurel Court on August 19, 2024....
Resident #25 had a bowel movement early on the morning of October 20, 2025, and activated her call light around 8:00 A.M....
The deficiency, tagged F0887, references CDC guidance on COVID-19 vaccine considerations for healthcare providers....
The resident died shortly after being readmitted to Bonita Hills Post Acute....
CNA #1 revealed during a phone interview that she was asked by CNA #2 to assist in transferring the resident into her transfer chair....
Resident C had large B-cell lymphoma affecting lymph nodes throughout his body....
The incident unfolded on August 30 when Resident #1, who had a history of wandering behavior, disappeared from the nursing station sometime after 6:15 p.m....
The incident occurred on October 18, 2025, during the 11 p.m....
Resident #148 fell on September 24, 2025....
The violations affected residents who remained at the facility for weeks without anyone determining their preferences for future living arrangements....
The resident required the extra-large sling based on measurements from the base of their spine to the top of their shoulder, the DON explained to inspectors....
The nurse failed to secure the resident's urinary catheter and committed a basic error that could increase infection risk....
None of these assessments appeared in the resident's official care plan or MDS evaluation upon admission....
Instead, multiple visit notes sat unsigned and unrecorded until the physician uploaded them in batches weeks later....
The attending nurse practitioner had prescribed Zosyn, a broad-spectrum antibiotic specifically for the patient's infections....
Resident #15 had a suprapubic catheter that required a securement device to prevent dangerous dislodgement....
The man has Alzheimer's disease, kidney disease, and requires maximum assistance with nearly every daily activity....
But the care plan told a different story....