Latest reports, citations, and penalties from CMS data
Resident 1 at Coventry Court Health Center was found lying on his left side outside his room on August 28, according to inspection records....
His hospital discharge papers were explicit....
Hallway surveillance cameras captured the deadly sequence at approximately 6:00 p.m....
State inspectors found the violation during a September 25 complaint investigation at the Pacific Avenue facility....
Records showed the person hadn't received or had refused baths on multiple dates, with no hair shampooing recorded from August 26 through September 23....
The confusion at Pelican Ridge Post Acute extended beyond missed tracking....
The resident told inspectors on September 23 that he needed to be changed....
The fall happened on September 19....
But that single competent performance masked deeper problems....
Staff also didn't notify the resident's doctor or family about either incident....
The family member reported the incident to facility staff immediately....
Resident 7 was admitted to the facility in August 2024 with multiple diagnoses including bacteremia, depression and anemia....
Resident 8 hit the floor next to their bedroom door on September 14....
A witness watched Staff #35 put the spoon in the resident's mouth as they shouted "I'm not taking this, what are you giving me....
The same pattern emerged across multiple residents who filed grievances that month....
Resident 33 was alone in the shared shower room adjacent to her bedroom on August 10 when she felt unstable while dressing....
The dishwasher's chlorine sanitizing levels measured just 10 parts per million - one-tenth of the minimum required concentration....
No other physician visits were documented in the resident's electronic medical record during the inspection period that stretched into September....
Highland Hills Post Acute discharged Resident R4 from therapy on September 4, with specific instructions for evening and morning splint care....
Resident #1 had valid orders for the pain medications dating back to May and June....