Latest reports, citations, and penalties from CMS data
The inspection, completed September 30, 2025, was triggered by a formal complaint, assigned case number 2624787....
But the designation also carried a specific qualifier: potential for more than minimal harm....
Inspectors classified it as an isolated deficiency with no actual harm documented, but with potential for more than minimal harm to residents....
Eight deficiencies in a single inspection is a substantial number for any facility, and infection control was among them....
The citation was one of six deficiencies recorded during a complaint inspection completed on October 2, 2025....
That is what the public record shows....
The citation falls under a category inspectors call environmental deficiencies....
Inspectors classified the violation as a pattern, meaning it wasn't an isolated instance....
The citation that followed was an Immediate Jeopardy, the most serious level of deficiency the Centers for Medicare and Medicaid Services can assign....
Months later, that same resident ended up in a local emergency room with a head injury, a scalp abrasion, and a scalp hematoma....
That last phrase carries weight....
Inspectors rated the violation at Scope/Severity Level D, meaning it was isolated in scope and caused no documented actual harm....
The inspection, completed in October 2025, was triggered by a complaint....
The violation was one of eight deficiencies cited during the complaint inspection....
That finding was one of 39 deficiencies cited during the September 30 inspection of the facility....
It was happening across enough of the facility's operations to constitute a recurring problem....
Inspectors determined the deficiency was widespread, meaning the breakdown was not isolated to a single lapse or a single corner of the building....
The citation against 24th Place came out of a complaint inspection conducted on October 2, 2025....
Federal inspectors who visited the facility on October 8, 2025 documented the lapse in detail....
The violation fell under a regulatory category covering how facilities procure, store, prepare, and serve food....