Latest reports, citations, and penalties from CMS data
That is the core of what federal inspectors documented when they visited the facility at 9401 South Ridgeland Avenue on October 22, 2025....
The order was specific: do not manipulate, flush, or exchange the catheter....
None of it was written down anywhere a caregiver could find it....
She told inspectors she thought the hydration and snack issue was being tracked....
The October 21 inspection, triggered by the complaint, found no current violations....
The problems inspectors identified cut across multiple layers of the facility's safety system....
Two other staff members, V9 and V10, were similarly unaware that a walker was part of her care plan or why it had been prescribed....
That gap, between what happened on August 21 and what the family was never told, sat undiscovered until a complaint inspection on October 22....
The social worker, identified in the inspection report only as SW24, had been too passionate, the record states....
That account came from the Director of Nursing at Adel Acres, who described the incident to inspectors during a complaint investigation completed October 16....
Federal inspectors documented the contradiction during a complaint investigation completed October 21, 2025....
Resident 35 turned on her call light at 11:00 AM on October 8, 2025....
The resident who had been hit, identified in inspection records as R2, was on the floor....
CNA-C's first day at Bethany Home was August 26, 2025....
The medication was stopped in July 2025 before a procedure to place a suprapubic catheter....
LPN-A, who had just returned from a week off, saw nothing alarming....
That's what inspectors found at Optalis Health and Rehabilitation of Three Rivers during a complaint inspection that wrapped October 22....
The inspection, completed October 23, 2025, was triggered by a complaint....
The failure was not a matter of missing paperwork on a single chaotic shift....
The resident had a urinary tract infection....