Latest reports, citations, and penalties from CMS data
Inspectors reviewing medication and treatment administration records found blank spaces on multiple dates in February 2025, including February 23 and 24....
The pattern surfaced during a complaint inspection completed August 29, 2025....
The resident, identified in inspection records only as R82, was incontinent of bladder and had fallen multiple times....
On at least five separate dates â July 15, July 24, August 1, August 5, and August 27 â output was recorded as zero....
The fall on June 28 resulted in the resident being sent to the emergency room....
Three nursing aides said the same thing....
The logs showed temperatures as low as 30 degrees, recorded across morning and evening checks spanning more than three weeks....
The resident in question, identified in inspection records only as Resident 1, has lived at Garden Crest since July 30, 2021....
The resident, identified in inspection records only as R8, is cognitively intact and knows what is happening around her....
The resident, identified in inspection records as R801, was eventually sent to the hospital at 2:30 AM....
That is what federal inspectors found when they arrived at the 137-bed nursing home on 255 Front Street on August 30, 2025, following a formal complaint....
The complaint inspection at The Estates of St....
None had labels identifying what they were or when they were prepared....
Federal inspectors arrived on August 29 and began asking questions....
The resident, identified in inspection records only as R1, was seen by a physician on July 21, 2025, after the daughter's call....
None of that was happening consistently....
When she entered the room, she found him upset over the spilled dessert and began helping him clean it up....
Inspectors first noticed it on August 25, 2025, at 12:36 in the afternoon....
The facility, at 1922 County Road NN in Elkhorn, serves residents in a dedicated memory care unit....
No place in a hallway or common area where a resident could quietly slip in a form and walk away....