Latest reports, citations, and penalties from CMS data
The inspection report, dated January 29, 2026, reveals a facility scrambling to contain damage from staff misconduct....
The resident had lived at Ansley Cove Healthcare and Rehabilitation for approximately nine years before her death....
The error meant emergency staff would see "DNR" in the system and let the resident die instead of attempting to save their life....
Inspectors documented a **pattern of deficiencies** affecting multiple residents, though no immediate physical harm was observed....
The oversight left contradictory instructions in the resident's file for months....
These citations require facilities to implement immediate corrective actions to remove the jeopardy situation....
The infection control violation occurred during care of a resident with a suprapubic catheter....
Resident 85 arrived at the facility on December 16, 2025, with multiple serious conditions....
Inspectors discovered staff violated these protocols during their review of dialysis care practices....
The incident occurred at Fortuna Rehabilitation and Wellness Center, where the resident had been receiving palliative care since October 2025....
Staff at Live Oak Rehab Center found the resident multiple times in late January wrapping her gown strings and gastrostomy tube around her finger....
Inspectors classified the violation as causing minimal harm or potential for actual harm to a few residents....
Inspectors determined the deficient record-keeping affected few residents but created minimal harm or potential for actual harm....
When these standards are not met, the risk of accidents, injuries, and health complications increases significantly for vulnerable nursing home residents....
The facility violated regulations requiring nursing homes to notify residents and their representatives in writing before any transfer or discharge....
Under that protocol, staff are required to wear gowns and gloves during hands-on care for residents who have indwelling medical devices or open wounds....
Federal inspectors documented the failure during a complaint inspection on January 29, 2026....
That finding sits at the center of a complaint inspection completed January 29, 2026, at the Palm Desert nursing home....
Employee E3 told state inspectors on January 29 that she never verified whether the resident's representative had been notified about the transfer....
Inspectors touring the floor with the nursing home administrator that morning measured nine rooms....